Showing papers in "Journal of Postgraduate Medicine in 2021"

New markers in predicting the severity of acute pancreatitis in the emergency department: Immature granulocyte count and percentage.

Abstract: Background: Acute pancreatitis (AP) may vary in severity, from mild, self-limiting pancreatic inflammation to rapidly progressive life-threatening clinical course. If the severity of AP can be predicted early and treated quickly, it may lead to a decrease in morbidity and mortality rates. There?fore, we aimed to investigate the clinical utility of immature granulocyte count (IGC) and IGC percentage (IG%) in showing the severity of AP in this study. Methods: Two hundred and twenty-seven patients who were admitted to our emergency department and diagnosed with AP between March 1 and September 30, 2019, were included in the study. The patients were divided into two groups as mild and severe AP (MAP and SAP) according to the severity of the disease. Demographic characteristics of the patients, disease etiology, disease severity, and inflammation markers [white blood cell count (WBC), IGC, IG%, neutrophil–lymphocyte ratio (NLR), and C-reactive protein (CRP)] were recorded. Differences between the groups were statistically analyzed. Results: Of the patients included in the study, 183 (80.7%) were in the MAP group and 44 (19.3%) were in the SAP group. The mean WBC, NLR, CRP, IGC, and IG% levels were significantly higher in the SAP group compared to the MAP group. The power of IGC and IG% in predicting SAP was higher than other inflammation markers (WBC, NLR, and CRP) [(AUC for IGC: 0.902; sensitivity: 78.2%; specificity: 92.8%); (AUC for IG%: 0.843; sensitivity: 72.7%; specificity: 84.6%)]. Conclusion: IGC and IG% show the severity of AP more effectively than WBC, NLR, and CRP, which are traditional inflammation markers.

Convalescent plasma, cytomegalovirus infection, and persistent leukopenia in COVID-19 recovery phase: What is the link?

Abstract: Therapies used to tide over acute crisis of COVID-19 infection may lower the immunity, which can lead to secondary infection or a reactivation of latent infection. We report a 75-years-old male patient who had suffered from severe COVID-19 infection three weeks earlier and who had been treated with corticosteroids and convalescent plasma along with other supportive therapies. At time of discharge he had developed leukopenia which worsened at 1-week follow up visit. On 18th day post-discharge, he became very sick and was brought to our hospital with complaints of severe persistent dysphagia. During evaluation he was diagnosed to have an acute cytomegalovirus infection and severe oropharyngeal thrush. Both COVID-19 and cytomegalovirus are known to cause synergistic decrease in T cells and NK cells leading to immunosuppression. The patient made complete recovery with a course of intravenous ganciclovir and fluconazole. Persistent leukopenia in high risk and severely ill cases should give rise to a suspicion of COVID-19 and cytomegalovirus co-infection.

Subcutaneous sarcoidosis: A case series of 19 patients.

Abstract: Subcutaneous sarcoidosis is a rare variant of this disease, whose relationship with systemic disease is still controversial. Our objective was to describe the clinical characteristics of a series of patients with subcutaneous sarcoidosis and to investigate the relationship between these skin lesions and the disease's activity, severity, and prognosis. Nineteen patients with biopsy-confirmed subcutaneous sarcoidosis between 2009 and 2019 were selected. Mean age at diagnosis was 53 years. Lung involvement was detected in 10 patients (52.6%), mainly in stages I and II. Only two patients (10.5%) had additional systemic signs and five patients (26%) suffered from other autoimmune diseases simultaneously. Six patients (31.6%) had elevated angiotensin-converting enzyme levels (mean level 174.5 U/L). Eight patients (42%) received treatment, mainly systemic corticosteroids, and all patients except for one had a favorable clinical outcome. Subcutaneous sarcoidosis is frequently associated with a mild form of systemic disease, and the prognosis seems favorable regardless of treatment. Sarcoid nodules could be an early finding of systemic disease, allowing for less invasive procedures for histological confirmation.

Blended programmatic assessment for competency based curricula.

Abstract: The uncertainty in all spheres of higher education due to the COVID-19 pandemic has had an unprecedented impact on teaching-learning and assessments in medical colleges across the globe The conventional ways of assessment are now neither possible nor practical for certifying medical graduates This has necessitated thoughtful considerations in making adjustments to the assessment system, with most institutions transitioning to online assessments that so far have remained underutilized Programmatic assessment encourages the deliberate and longitudinal use of diverse assessment methods to maximize learning and assessment and at present can be utilized optimally as it ensures the collection of multiple low-stake assessment data which can be aggregated for high-stake pass/fail decisions by making use of every opportunity for formative feedback to improve performance Though efforts have been made to introduce programmatic assessment in the competency-based undergraduate curriculum, transitioning to online assessment can be a potential opportunity if the basic tenets of programmatic assessment, choice of online assessment tools, strategies, good practices of online assessments and challenges are understood and explored explicitly for designing and implementing online assessments This paper explores the possibility of introducing online assessment with face-to-face assessment and structuring a blended programmatic assessment in competency-based medical education

The association of plasma acyl ghrelin level with alcohol craving in early abstinent alcohol dependent patients.

Abstract: Background: Craving plays an important role in maintenance of alcohol dependence. Earlier studies have analyzed the role of ghrelin in craving and their results have been heterogenous. Acyl ghrelin is its more active form as it crosses the blood brain barrier. Hence we aimed to examine the relationship between plasma acyl ghrelin and craving in Indian patients having alcohol dependence syndrome. Methods: The present study was a hospital-based prospective study. A total of 60 drug-naive patients of alcohol dependence and 30 healthy controls were included. After taking informed consent fasting blood samples were collected from them on day 1 and tested for plasma acyl ghrelin level. Fasting blood samples were repeated in all cases on day 14. During this time, we also assessed the patients' cravings by obsessive compulsive drinking scale, and alcohol craving questionnaire; and withdrawal by clinical institute withdrawal assessment for alcohol scale. These scales were repeated on day 14. Data analysis was done by SPSS version 25.0. Results: Plasma concentrations of acyl ghrelin increased significantly during early abstinence in patients from day 1 to day 14 (P

Evaluation of pharmacokinetics of single-dose primaquine in undernourished versus normally nourished children diagnosed with Plasmodium vivax malaria in Mumbai.

Abstract: Background: The pharmacokinetics of primaquine [PQ] have been the subject of studies in both adults and healthy participants. However, there is no study on its pharmacokinetics in a setting of undernourishment. In India, there is evidence to show considerable malnourishment in children that in turn can affect drug pharmacokinetics. Given that the country is moving towards malaria elimination, the present study was planned with the objective of comparing pharmacokinetics of the drug in undernourished children relative to normally nourished children. Materials and Methods: After Institutional Ethics Committee approval, children of either gender between the ages of 5 and 12 years and smear-positive for Plasmodium vivax malaria were included. Nourishment status was determined using the Indian Academy of Pediatrics classification of protein energy malnutrition based on Khadilkar's growth charts. Twelve children each were enrolled in the two groups. PQ was given in the dose of 0.3 mg/kg/d and blood collections were made at 0, 1, 2, 3, 4, 6, 8 and 24 hours post-dosing. Levels were estimated by high-performance liquid chromatography. Chloroquine in the dose of 25 mg/kg was given over three days along with supportive care. Results: Of the 24 children, there were 17 boys and 7 girls. There was a statistically significant difference in the body weight between the undernourished and the normally nourished children [21.5 ± 5.52 vs. 28.8 ± 8.84, P

Effect of testosterone replacement therapy on insulin sensitivity and body composition in congenital hypogonadism: A prospective longitudinal follow-up study.

Abstract: Aims: To evaluate the prevalence of metabolic syndrome (MS) and whole-body composition in patients with congenital hypogonadism and investigate the effects of replacement therapy with testosterone undecanoate on MS, insulin resistance (IR), and whole-body composition in subset of patients. Methods: In a single arm prospective longitudinal intervention study, 33 patients with congenital hypogonadism, ages 20–39 years, were recruited and their parameters of MS, whole-body composition by DXA were compared with age and BMI matched healthy controls. In 21 patients, after 9 months we prospectively studied the effect (pre–post difference) of injection testosterone undecanoate (1,000 mg) replacement on MS, IR, and whole-body compositions. Results: The prevalence of MS was similar in patients and controls (27.3% vs. 9.1%, P = 0.05). Hypogonadism patients had higher prevalence of hypertension (33% vs. 3%, P Conclusion: In this study, 36 weeks of testosterone replacement resulted in significant decrease in waist circumference, IR, truncal fat, total body fat and improvement in lean body mass, and insulin sensitivity.

A case of premature and recurrent myocardial infarction associated with ABCA.1 gene mutation.

Abstract: Coronary heart disease (CHD) is the most important cause of cardiovascular death and when premature, it affects the most productive population of the community. Premature CHD usually has a specific etiology, which on diagnosis, might help in the secondary prevention in that individual. We report a case of young adult with recurrent myocardial infarction, who on evaluation had mildly reduced HDL and Protein C levels with elevated serum homocysteine. Clinical exome identified a possibly pathogenic variant of ABCA1 gene, associated with Tangier disease.

Swallowing-induced supraventricular arrhythmia: A different perspective to mechanism.

Abstract: Atypical presentations of supraventricular arrhythmias constitute a diagnostic challenge which are not frequently reported in literature. Swallowing-induced supraventricular arrhythmia (SI-SVA), which was first described in 1926, is an intriguing presentation of supraventricular tachycardia and occurs during a wet or solid swallow. A 67-year-old man presented to our outpatient clinic complaining from recurrent episodes of sensation of palpitations and short duration pressure on his chest while swallowing since the last 2 weeks. Ambulatory rhythm Holter monitoring was suggestive of atrial fibrillation (AF) or atrial tachycardia attacks during swallowing. In addition, electrocardiography performed during solid food swallowing, showed short duration of AF consistent with the patient's symptoms. The patient was successfully treated with amiodarone. The main cause of SI-SVA is not known. Cross-talk of nerves during the impulse propagation might be the underlying cause of this phenomenon.

Could pure agraphia be the only sign of stroke? Lessons from two case reports

Abstract: Agraphia is defined as the disruption of the previously intact writing skills due to an acquired brain damage. Stroke remains the most common cause of language impairment; however, writing disorders, including agraphia, are underestimated in patients with stroke. In this regard, we report two patients presenting with pure agraphia as an early symptom of stroke. Both patients complained of at least two difficulties in visualizing letter formation beforehand, the frequent need for verbal cues, misuse of lines and margins, poorly legible signature, and writing and thinking at the same time (e.g., creative thinking and taking notes). They underwent brain magnetic resonance imaging which revealed a small lacunar infarction of the left insula and external capsule (patient 1) and a small hemorrhagic lesion in the posterior limb of the left internal capsule (patient 2). To our knowledge, this is the first report on pure agraphia as the presenting symptom of stroke. We suggest that all patients with acute agraphia, even when presenting as an isolated symptom, should be evaluated for stroke, in order to better facilitate its diagnosis and treatment.

Glyphosate poisoning - a case report.

Abstract: Glyphosate is the most commonly used broad-spectrum, non-selective herbicide in the world The toxicity is supposed to be due to uncoupling of oxidative phosphorylation and the surfactant polyoxyethylene amine (POEA)- mediated cardiotoxicity Clinical features of this herbicide poisoning are varied, ranging from asymptomatic to even death There is no antidote and aggressive supportive therapy is the mainstay of treatment for glyphosate poisoning We present a 69-year-old female patient with suicidal consumption of around 500 ml of Glycel® Initially, gastric lavage was done and intravenous fluids were given Within two hours of presentation, the patient developed respiratory distress needing intubation, hypotension needing vasopressor support, and severe lactic acidosis She also developed acute respiratory distress syndrome, hypokalemia, hypernatremia, and aspiration pneumonia Our patient was critically ill with multiple poor prognostic factors, but with timely aggressive supportive management, the patient gradually recovered

Pembrolizumab-induced large duct cholangiopathy: Diagnosis and follow.up imaging

Abstract: Immune-checkpoint inhibitor mediated hepatobiliary injury is an emerging concern in cancer treatment Most of these adverse reactions are attributed to nivolumab and are characterized by panlobular hepatitis Large duct cholangiopathy related to these drugs is extremely rare We present a case of adenocarcinoma of lung treated with pembrolizumab who developed biochemical and imaging features consistent with cholangiopathy characterized by common bile duct dilatation, wall enhancement, and gallbladder wall edema On follow-up in the fourth month, the imaging features persisted despite the normalization of liver enzymes To the best of our knowledge, this is the first description of diagnosis and follow-up imaging of pembrolizumab-related cholangiopathy in imaging literature

DRESS syndrome induced by imatinib.

Abstract: Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia and elevated liver enzymes. The severity and potential organ damage associated with DRESS mandates withdrawing the offending drug and provide a suitable replacement. We report a 55-year-old man who developed prolonged fever, generalized maculopapular rash and facial edema after 3 weeks of starting imatinib for chronic myeloid leukemia (CML). A diagnosis of DRESS was confirmed by eosinophilia and skin biopsy findings, along with a consistent RegiSCAR score. Imatinib was stopped and he was initiated on low-dose steroids, which led to complete resolution of rash and eosinophilia. A rechallenge with imatinib was positive, and he was switched to dasatinib for further therapy, following which he attained an optimal molecular response. DRESS following imatinib has only been reported in eight patients so far. In this report we summarize the current evidence for managing DRESS and its impact on the treatment of CML.

Unusual presentation of an insulinoma in an elderly male patient.

Abstract: Insulinoma is a rare neuroendocrine tumor originating from hypersecreting beta-cells of islets of Langerhans in the pancreas. We report a case of 72-year-old male, with chronic alcohol abuse, presenting with atypical features like refractory recurrent secondary generalized seizures and behavioral disturbances with increased irritability, initially mistreated as alcohol withdrawal. Detailed history, particularly the relationship of the symptoms with food intake, made us think of other causes of seizures. Fasting biochemical investigations and localizing studies helped clinch the diagnosis. The tumor was localized with the help of endoscopic ultrasonography and whole-body Ga68-DOTANOC PET-CT. The patient was treated conservatively with diazoxide and is doing well on follow-up. The present case report emphasizes the importance of detailed clinical history, more so in atypically presenting cases of refractory seizures. Insulinoma can be medically managed despite surgery being the gold standard curative treatment.

Isolated aquagenic acrokeratoderma of dorsal hands.

Abstract: A 31-year old male, software-engineer, presented with a 2-month history of asymptomatic wrinkling and roughness of hands within minutes of washing hands/immersion in water. Patient was otherwise healthy and there was no history of respiratory, gastrointestinal complaints or any other comorbidities. There was no history of atopy, hyperhidrosis, activities which might lead to barrier damage or any prior drug intake including NSAIDs and aminoglycosides. He was married for 1 year and didn’t have any children till then. There was no history of similar complaints or cystic fibrosis in the family. Preexposure, the cutaneous examination was normal. He was asked to immerse his hands and feet in a water-filled container. Within 1-2 minutes of this, he developed multiple well-defined skin-colored to whitish tiny papules over dorsum of both hands. Skin of the palms and feet was normal [Figures 1 and 2]. Rest of the cutaneous examination was normal as well. The papules subsided within 15–20 minutes of drying the hands. Histopathology of skin biopsy sample, taken from the papules postimmersion in water showed an epidermis with hyperkeratosis, orthokeratosis, and focal acanthosis; focal eccrine ducts showed dilatation and dermis showed minimal lymphomononuclear cell infiltrate [Figure 1]. The patient was also screened for cystic fibrosis through investigations such as serum electrolytes, stool examination for fat globules and chest X-ray; all of which were normal. The patient refused any further testing. A diagnosis of aquagenic acrokeratoderma was made. The patient was advised frequent use of emollients and was counselled about recurrent, transient, and benign course of the condition. He showed partial improvement in 4 weeks with emollients and further, the patient was lost to follow-up. Aquagenic acrokeratoderma is also known as aquagenic wrinkling of the palm, acquired aquagenic papulotranslucent acrokeratoderma and aquagenic syringeal acrokeratoderma.[1] It is an uncommon condition characterized by development of multiple, tiny skin-colored to whitish pebbly papules over the palms and rarely over the soles; within minutes of exposure to water. The condition can be asymptomatic or present with pain, burning sensation, pruritus, and paresthesia.[2] The etiopathogenesis is poorly understood. Many hypotheses have been laid such as genetic susceptibility, impaired epidermal barrier function which causes enhanced water absorption, transient structural, or functional modifications in stratum corneum leading to alteration in eccrine sweat ducts. It has also been postulated that transient skin barrier damage could occur in susceptible individuals on prolonged exposure to water or external agents like detergents. It has been reported in association with cystic fibrosisboth patients and carriers, and with the use of cyclooxygenase2 inhibitors, thus supporting the role of impaired barrier function and increased sweat salt concentration leading to sodium retention in epidermis that causes increased water absorption and development of lesions on exposure to water. Palmoplantar hyperhidrosis and atopic diathesis are also associated.[3,4] In a minority, it can be a presenting feature of atypical cystic fibrosis manifesting in adulthood. Therefore, relevant history and investigations including genetic testing is advisable to rule out milder phenotypes and carriers of cystic fibrosis.[2] Some cases can remit spontaneously over time, possibly due to recovery of the damaged skin barrier.[5] The histopathological examination of lesional skin reveals orthohyperkeratosis/normal epidermis with dilatation of eccrine ducts. Treatment includes topicals like aluminum chloride hexahydrate, urea, salicylic acid, ammonium lactate, and botulinum injections. Mostly, the response to treatment is unsatisfactory.[4]

Multiple extubation failures following a rhino-enteroviral infection: A unique case report in a pediatric patient

Abstract: This case report reviews the hospital course of a 15-month-old girl admitted to the PICU for acute respiratory failure due to enterovirus infection; who subsequently had multiple extubation failures secondary to acute transverse myelitis. This rare presentation highlights the importance of assessing the neurological status in a patient with rhino-enteroviral respiratory infection and of considering acute transverse myelitis as an etiology for difficulty with extubation.

Unraveling a cephalalgic quagmire from a cavern to a cave.

Abstract: Headache in women in their late forties can be primary or secondary. We report a 48-year-old female with chronic slowly progressive left temporal headache for 1 year. She also had ipsilateral eye pain and facial numbness for 1 month, with restricted abduction in the left eye and diplopia. On neurological examination, she had isolated left abducent nerve palsy, with loss of corneal and conjunctival reflexes, localizing the pathology to the cavernous sinus or its adjacent structures. Anatomically, cranial nerves V and VI are in close proximity to each other in the region of Meckel's cave. In view of her age, insidious onset, progressive symptoms and clinical findings, the provisional diagnosis in this patient was a Meckel's cave tumor. Magnetic resonance (MR) imaging revealed a 2 cm × 2 cm × 1.7 cm enhancing dumb-bell-shaped mass lesion with mild restricted diffusion in the Meckel's cave projecting into cavernous sinus with alanine, myoinositol and glutamine peaks on MR spectroscopy. Intradural debulking was done; lesion was confirmed by histopathology and patient was cured of her symptoms. An algorithm for diagnosing this entity at the bedside is presented.