Intracranial aspergillosis (ICA) is very rare in the immunocompetent individuals, usually misdiag... more Intracranial aspergillosis (ICA) is very rare in the immunocompetent individuals, usually misdiagnosed as a tumor or an abscess. A high index of clinical suspicion is required in patients who present with focal neurological deficits, headache, or seizures. We report the case of a 25-year-old immunocompetent female, who presented with a 15-month history of headache, seizures, left-sided proptosis and ophthal-moplegia, and right hemiparesis. Recovery from the symptoms and decrease in the lesion size seen on the radiological assessment were achieved through two decompressive craniotomies followed by prolonged combined systemic antifungal therapies. Although the initial neuroimaging suggested a mitotic pathology, the surgical sample confirmed ICA. Now the patient is on single antifungal therapy (Tab. voriconazole, 200 mg twice daily) and doing her daily activities, but with a reduced intelligent quotient. We report a challenging case of ICA where multiple courses of combined antifungal therapies and repeat surgeries paved the way for a good prognosis.
Visceral leishmaniasis (VL) is a vector-borne parasitic disease, caused by Leishmania donovani sp... more Visceral leishmaniasis (VL) is a vector-borne parasitic disease, caused by Leishmania donovani species complex , predominantly affecting tissue macrophages. It is the second largest cause of parasitic death after malaria and is responsible for an estimated 2–4 lakhs cases per year worldwide 1. The anthroponotic form, L. donovani is prevalent in the Indian subcontinent and East Africa. Eastern states of India, namely Bihar, Jharkhand, Uttar Pradesh and West Bengal are considered as endemic zone, but sporadic cases have been reported from other areas too 2. Patients with VL usually present with fever, weight loss, splenomegaly, and cytopenias 3. Rarely, it can present with atypical manifestations which can lead to delay in diagnosis or misdiagnosis 4. Seroepidemiological and molecular analyses have shown that progression to VL occurs only in <10% of all leishmania infections, indicating the role of certain risk factors 5. HIV, malnutrition, old age, neoplastic diseases, transplantation and immu-nosuppressive therapy increases the risk of acquiring the infection 6. Because of chronic immunosuppressive disease state,VL can predispose to frequent bacterial infections and sepsis is the most common cause of mortality 7. We report a classic case of VL from non-endemic zone in India that initially mimicked as a rheumatic disease and was subsequently diagnosed to have hemophagocytic syndrome/hemophagocytic lymphohistiocytosis (HLH) with submasseteric abscess. Case report A 25-yr-old female (home maker), from Madhya Pradesh, India, presented at All India Institute of Medical Sciences (AIIMS) Hospital, New Delhi with history of moderate grade continuous fever, arthralgia involving large joints (only four) for six months and swelling over left side of face for one week. The arthralgia (without joint swelling and significant morning stiffness) had developed one month after the fever. There was no significant weight loss, photosensitivity, alopecia, Raynaud's phenomenon, dry mouth, or bleeding from any sites. Earlier laboratory reports (from outside), showed that patient had pancytopenia with Hb (62 g/l), TLC (1.2 × 10 9 /l), and platelets (68 × 10 9 /l). Rheumatoid factor (RF), anti-nuclear antibody (ANA) and antidouble stranded DNA antibodies (anti-dsDNAs) were negative, while anticyclic citrullinated peptide (anti-CCP) antibody titre was elevated (50.1 U/ml, normal range <15). Other laboratory investigations including imaging of brain, spinal fluid analysis, and liver biopsy were also done, but no specific cause of underlying condition could be made. She was documented as a case of adult-onset still's disease (AOSD) and started on disease modifying antirheumatic drugs (DMARDs) which she took irregularly. Around five months from the onset of fever, the patient developed a swelling in the left side of the face. The swelling started in the area of the left angle of man-dible, progressively increased in size, and the patient subsequently developed painful trismus. The patient did not report any previous history of dental problem or local trauma. Since, the initial symptoms of fever and arthral-gia were persisting and the patient also had new onset of swelling on the face and she was referred to New Delhi's AIIMS Hospital for further management. On examination, she was febrile with tachycardia and tachypnoea. There was a swelling over left side of face extending from the lower border of the zygomatic arch down to the submandibular region, which was 3 × 2 cm in size with signs of inflammation and reduced mouth opening due to trismus. Abdominal examination revealed hepatosplenomegaly. Haemogram revealed Hb 85 g/dl, TLC 0.6 × 10 9 /l
Respiratory distress is very uncommon as a presenting symptom of Chilaiditi syndrome. Furthermore... more Respiratory distress is very uncommon as a presenting symptom of Chilaiditi syndrome. Furthermore, pneumonia is not documented with the syndrome, compromising further to the distress. We describe a middle-aged man, chronic alcoholic, recently diagnosed with liver cirrhosis, presented with a 1-year history of slowly progressive breathlessness. Recently, he developed mild-to-moderate hemoptysis and cough with aggravation of breathlessness. He did not have fever, chest pain, or orthopnea. He was cyanosed, requiring high-dose oxygen therapy. Later on, he stabilized with noninvasive ventilation. Chest imagings showed incidental Chilaiditi sign, liver cirrhosis, and atypical pneumonitis. With empirical antibiotics and high-dose steroid, he recovered completely but with baseline breathlessness. Here, we outline Chilaiditi syndrome as a rare association or manifestation of liver cirrhosis, and it can present with a respiratory compromise by both obstructive lung disease and atypical interstitial pneumonia. Early identification, vaccinations against common organisms, and possible early surgery may prevent morbidity and mortality of this type of patients.
The relationship between cortisol level and sepsis is not known in Indian patients of severe seps... more The relationship between cortisol level and sepsis is not known in Indian patients of severe sepsis/septic shock. Aims: The study was done to determine the optimal range of cortisol levels, defining the adrenocortical response, and predicting the mortality, if possible, in the above type of patients. Settings and Designs: The study was a single-centered prospective cohort study, conducted in a tertiary referral center, North India. Materials and Methods: Sixty patients with severe sepsis (n = 30) and septic shock (n = 30) were recruited. Basal and postcosyntropin (1 µg)-stimulated cortisol levels were measured, and all patients were closely monitored with daily assessments of clinical and laboratory variables. Western diagnostic criteria were followed for defining adrenal insufficiency (AI). The end point was the survival assessed at day 28 or death, whichever came earlier. Results: The mean basal (T0) and poststimulation (T30) cortisol levels were 31.77 ± 15.9 µg/dL and 37.58 ± 17.31 µg/dL, respectively. In all sepsis patients, 48.33% qualified as AI at T0 ≤ 24 µg/dL, 61.67% at delta cortisol (∆ = T30-T0) ≤7 µg/dL, and 78.33% at ∆ ≤9 µg/dL. Using receiver operating characteristic curve, the area under the curve (AUC) was 0.4954, signifying poor prediction to death. Conclusions: Indians have completely different characteristics of cortisol levels in sepsis patients, in comparison to the Western data. They have higher range of basal cortisol levels, higher percentage of AI, and an inability to predict mortality with the cortisol levels. Hence, there is requirement of an international study to confirm the dichotomy of the results.
Non-alcoholic Fatty Liver Disease (NAFLD) is currently reliably and increasingly being diagnosed ... more Non-alcoholic Fatty Liver Disease (NAFLD) is currently reliably and increasingly being diagnosed and classified by non-invasive methods in comparison with standard invasive methods. Various permutations and combinations has been studied and explored with different clinical sign and symptoms with or without lab profiles to closely approach the precise diagnosis. It is indeed the need of the hour to understand the most suitable non-invasive clinical modality in a given set of patient profile to reach to the finest and closest diagnosis without compromising the outcome as far as the patient management is concerned. This could well be learnt progressively to more and more effectively use of these non-invasive tools and avoiding cumbersome liver biopsy in parallel Fatty liver is frequently used terminology in the day to day reporting of routine and focused abdominal imaging. This leaves a good amount of stress and alarm on patients and their kin's mind. The most frequently asked question after these reports is 'what is the current status and what next ?' Various clinical methods extending from a single parameter to combination of various clinical laboratory profile has been tried to answer the question precisely. There are a lot of scores and system which exists in the literature but 'which one to use and where to use' is sporadically arranged making it difficult in usability. This is to simplify the same and make better understanding of the topic for the clinicians to objectively answer all the queries related to stage, grade and diagnose of this entity. Furthermore it is attempted to reliably use the non-invasive modalities of staging and grading to replace cumbersome liver biopsy without compromising the clinical benefits out of management dependent on these parameters. CONVENTIONAL METHODS NAFLD should strongly be suspected in patients with deranged liver enzymes and/or who have features of metabolic syndrome. However, before labelling a person as NAFLD extensive/detail history (alcohol abuse, drug intake) must be taken and serological studies (viral and autoimmune hepatitis, alpha-1-antitrypsin deficiency, hemochromatosis and Wilson's disease) should be done.
Dear Editor, Overlap syndrome (OS) is an uncommon rheumatological condition wherein there is an o... more Dear Editor, Overlap syndrome (OS) is an uncommon rheumatological condition wherein there is an occurrence of two or more well-defined connective tissue diseases (CTDs) at the same or at different times in the same patient. 1 While OS is most often described in association with systemic sclerosis, that involving idiopathic inflammatory myopathies (IIMs) are uncommon. Primary vasculitides were not encompassed in the above definition of OS until the publication of a few recent case reports. 2 Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) overlapped with IIM is even more rare. To the best of our knowledge, only two case reports of an overlap of AAV with dermatomyositis (DM) exist. There is a lack of such overlap cases in the children.
SUMMARY The approach to an intrinsic cause of superior vena cava syndrome (SVCS) is usually diffi... more SUMMARY The approach to an intrinsic cause of superior vena cava syndrome (SVCS) is usually difficult but rewarding. We report a case of a middle-aged man who presented with progressive oedema of the upper half of the body, dyspnoea, cough and weight loss for a 1-year duration. He was a non-smoker without prior hospitalisation. Chest radiography showed right-sided pleural effusion with an apparent normal superior mediastinum. Contrast-enhanced CT of the chest revealed a right atrial mass extending and completely obliterating to superior vena cava. The differentials were tuberculosis, invasive fungal granuloma, sarcoidosis, primary vasculitis, chronic venous thrombosis, cardiac sarcoma/lymphoma and metastatic thyroid tumour or thymoma. He underwent transvenous (femoral approach) biopsy of the mass and then cardiothoracic surgery after haemodynamic instability. Pathology showed invasive thymoma type B3. This case highlights the approach to an intrinsic cause of SVCS, a complication of the transvenous approach, and importantly a noble finding of venous spread metastasis. BACKGROUND
Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly Am... more Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly America, Africa, and Asia. In India, it is being reported from most states; however, it is endemic along the Ganges belt. We report a case of an apparently immunocompetent male who presented with 3-month history of fever, cough, and weight loss with recent onset odynophagia and had hepatosplenomegaly and mucocutaneous lesions over the face. The differential diagnosis of leishmaniasis, tuberculosis, leprosy, fungal infection, lymphoproliferative malignancy, and other granulomatous disorders was considered, but he succumbed to his illness. Antemortem skin biopsy and bone marrow aspiration along with postmortem liver, lung, and spleen biopsy showed disseminated histoplasmosis. This case highlights the need for an early suspicion of progressive disseminated histoplasmosis in the presence of classical mucocutaneous lesions even in an immunocompetent patient suffering from a febrile illness. Cure rate approaches almost 100% with early treatment, whereas it is universally fatal if left untreated.
India and neighboring Nepal, Bangladesh along with Sudan and Brazil
are the four largest foci of ... more India and neighboring Nepal, Bangladesh along with Sudan and Brazil are the four largest foci of visceral leishmaniasis and account for 90% of the world’s visceral leishmaniasis (VL) burden, with India being the worst affected. High degree of suspicion is usually based on patient presenting from endemic area with features of pancytopenia hepatosplenomegaly. Hemophagocytic lymphohistiocytic (HLH) syndrome also presents with similar clinical features. Visceral leishmaniasis leading to secondary HLH syndrome is in itself a rare entity while both of these presenting in pregnant patient, to the best knowledge of the authors, is yet to be described in literature.
Drug trafficking is an international problem. Over years it has increased in prevalence and conce... more Drug trafficking is an international problem. Over years it has increased in prevalence and concealment methods. Body packers swallow wrapped packets of illicit drugs, mainly cocaine and heroin and try to conceal them from security personnel. They present to physicians either as body packer syndrome with symptoms of intoxication or asymptomatically on suspicion of drug concealment, for observation. We report a case of middle aged unknown male, found in comatose state on road side by Delhi police (India), brought to our emergency without any signs of injury. Initially organophosphate toxidrome was suspected, later confirmed to be opiod toxidrome with internal concealment of many balloons (of polythene) wrapped packets of heroin. On failure of conservative removal, he underwent laparotomy with complete removal of all the packets. He was discharged in stable condition and handed over to the police. This is the first case report of live heroin body packer syndrome from India.
The objective is to study relation of HbA1c with cardiovascular disease risk factors in non-diabe... more The objective is to study relation of HbA1c with cardiovascular disease risk factors in non-diabetic subjects of Northern-India having coronary artery diseases. This hospital based analytic-cross sectional study was conducted in department of medicine at a tertiary care center in Northern-India during the period of March-July, 2012 among 69 admitted cases of CAD. Patients with CAD and had HbA1c 4-6.4 %, FPG< 100 mg/dL (< 5.55 mmol/L) or PPPG< 140 mg/dL(7.77 mmol/L) were included in this study. Patients who had diabetes, acute febrile illness, anemia (Hb< 10 g/dL in female &< 12 g/dL in male), hemoglobinopathy and who did not give informed consent were excluded from the study. CAD was defined based on documented history of myocardial infarction or ECG criteria as per Minnesota codes. Special INTERHEART questionnaires were being used for physical activity and dietary habits. A detail history and clinical examination was carried out. HbA1c was measured by chromatography analyzer (Turbidimetric HPLC method). BMI, WC, serum TC, TG, and LDL increased significantly with higher tertiles of HbA1c similar to known cardiovascular risk factors viz. family H/O premature CAD, dyslipidemia (high TG & low HDL) and obesity, especially, central type(P for trend < 0.05).The mean ± SD HbA1c value in the study cohort was 5.39 ± 0.78%. Mean HbA1c differed statistically significantly in subjects having unhealthy diet, obesity (including central type) and hypertriglyceridemia (p < 0.05). HbA1c had significant correlation with BMI (r=+0.429, p=0.0002), WC (r=+0.4311, p=0.0002), FPG (r=+0.394, p=0.0008), TG (r=+0.4151, p=0.0004), TC (r=+0.356, p=0.0027), LDL (r=+0.290, p=0.0168), and VLDL (r=+ 0.4101, p=0.0005). On multivariate analysis, BMI (β=+0.05, p=0.007) and FPG (β=+0.04, p=0.000) were significantly correlated. When separate correlation was done with FPG as dependent variable, no risk factors were significantly correlated. In non-diabetic CAD patients, HbA1c showed significant association with CVD risk factors i.e. obesity including central type and dyslipidemia (especially hypertriglyceridemia), typical of Asian Indian phenotype. Therefore, HbA1c might be a useful measure even among the non-diabetic population in assessing an individual's cardiovascular risk.
Intracranial aspergillosis (ICA) is very rare in the immunocompetent individuals, usually misdiag... more Intracranial aspergillosis (ICA) is very rare in the immunocompetent individuals, usually misdiagnosed as a tumor or an abscess. A high index of clinical suspicion is required in patients who present with focal neurological deficits, headache, or seizures. We report the case of a 25-year-old immunocompetent female, who presented with a 15-month history of headache, seizures, left-sided proptosis and ophthal-moplegia, and right hemiparesis. Recovery from the symptoms and decrease in the lesion size seen on the radiological assessment were achieved through two decompressive craniotomies followed by prolonged combined systemic antifungal therapies. Although the initial neuroimaging suggested a mitotic pathology, the surgical sample confirmed ICA. Now the patient is on single antifungal therapy (Tab. voriconazole, 200 mg twice daily) and doing her daily activities, but with a reduced intelligent quotient. We report a challenging case of ICA where multiple courses of combined antifungal therapies and repeat surgeries paved the way for a good prognosis.
Visceral leishmaniasis (VL) is a vector-borne parasitic disease, caused by Leishmania donovani sp... more Visceral leishmaniasis (VL) is a vector-borne parasitic disease, caused by Leishmania donovani species complex , predominantly affecting tissue macrophages. It is the second largest cause of parasitic death after malaria and is responsible for an estimated 2–4 lakhs cases per year worldwide 1. The anthroponotic form, L. donovani is prevalent in the Indian subcontinent and East Africa. Eastern states of India, namely Bihar, Jharkhand, Uttar Pradesh and West Bengal are considered as endemic zone, but sporadic cases have been reported from other areas too 2. Patients with VL usually present with fever, weight loss, splenomegaly, and cytopenias 3. Rarely, it can present with atypical manifestations which can lead to delay in diagnosis or misdiagnosis 4. Seroepidemiological and molecular analyses have shown that progression to VL occurs only in <10% of all leishmania infections, indicating the role of certain risk factors 5. HIV, malnutrition, old age, neoplastic diseases, transplantation and immu-nosuppressive therapy increases the risk of acquiring the infection 6. Because of chronic immunosuppressive disease state,VL can predispose to frequent bacterial infections and sepsis is the most common cause of mortality 7. We report a classic case of VL from non-endemic zone in India that initially mimicked as a rheumatic disease and was subsequently diagnosed to have hemophagocytic syndrome/hemophagocytic lymphohistiocytosis (HLH) with submasseteric abscess. Case report A 25-yr-old female (home maker), from Madhya Pradesh, India, presented at All India Institute of Medical Sciences (AIIMS) Hospital, New Delhi with history of moderate grade continuous fever, arthralgia involving large joints (only four) for six months and swelling over left side of face for one week. The arthralgia (without joint swelling and significant morning stiffness) had developed one month after the fever. There was no significant weight loss, photosensitivity, alopecia, Raynaud's phenomenon, dry mouth, or bleeding from any sites. Earlier laboratory reports (from outside), showed that patient had pancytopenia with Hb (62 g/l), TLC (1.2 × 10 9 /l), and platelets (68 × 10 9 /l). Rheumatoid factor (RF), anti-nuclear antibody (ANA) and antidouble stranded DNA antibodies (anti-dsDNAs) were negative, while anticyclic citrullinated peptide (anti-CCP) antibody titre was elevated (50.1 U/ml, normal range <15). Other laboratory investigations including imaging of brain, spinal fluid analysis, and liver biopsy were also done, but no specific cause of underlying condition could be made. She was documented as a case of adult-onset still's disease (AOSD) and started on disease modifying antirheumatic drugs (DMARDs) which she took irregularly. Around five months from the onset of fever, the patient developed a swelling in the left side of the face. The swelling started in the area of the left angle of man-dible, progressively increased in size, and the patient subsequently developed painful trismus. The patient did not report any previous history of dental problem or local trauma. Since, the initial symptoms of fever and arthral-gia were persisting and the patient also had new onset of swelling on the face and she was referred to New Delhi's AIIMS Hospital for further management. On examination, she was febrile with tachycardia and tachypnoea. There was a swelling over left side of face extending from the lower border of the zygomatic arch down to the submandibular region, which was 3 × 2 cm in size with signs of inflammation and reduced mouth opening due to trismus. Abdominal examination revealed hepatosplenomegaly. Haemogram revealed Hb 85 g/dl, TLC 0.6 × 10 9 /l
Respiratory distress is very uncommon as a presenting symptom of Chilaiditi syndrome. Furthermore... more Respiratory distress is very uncommon as a presenting symptom of Chilaiditi syndrome. Furthermore, pneumonia is not documented with the syndrome, compromising further to the distress. We describe a middle-aged man, chronic alcoholic, recently diagnosed with liver cirrhosis, presented with a 1-year history of slowly progressive breathlessness. Recently, he developed mild-to-moderate hemoptysis and cough with aggravation of breathlessness. He did not have fever, chest pain, or orthopnea. He was cyanosed, requiring high-dose oxygen therapy. Later on, he stabilized with noninvasive ventilation. Chest imagings showed incidental Chilaiditi sign, liver cirrhosis, and atypical pneumonitis. With empirical antibiotics and high-dose steroid, he recovered completely but with baseline breathlessness. Here, we outline Chilaiditi syndrome as a rare association or manifestation of liver cirrhosis, and it can present with a respiratory compromise by both obstructive lung disease and atypical interstitial pneumonia. Early identification, vaccinations against common organisms, and possible early surgery may prevent morbidity and mortality of this type of patients.
The relationship between cortisol level and sepsis is not known in Indian patients of severe seps... more The relationship between cortisol level and sepsis is not known in Indian patients of severe sepsis/septic shock. Aims: The study was done to determine the optimal range of cortisol levels, defining the adrenocortical response, and predicting the mortality, if possible, in the above type of patients. Settings and Designs: The study was a single-centered prospective cohort study, conducted in a tertiary referral center, North India. Materials and Methods: Sixty patients with severe sepsis (n = 30) and septic shock (n = 30) were recruited. Basal and postcosyntropin (1 µg)-stimulated cortisol levels were measured, and all patients were closely monitored with daily assessments of clinical and laboratory variables. Western diagnostic criteria were followed for defining adrenal insufficiency (AI). The end point was the survival assessed at day 28 or death, whichever came earlier. Results: The mean basal (T0) and poststimulation (T30) cortisol levels were 31.77 ± 15.9 µg/dL and 37.58 ± 17.31 µg/dL, respectively. In all sepsis patients, 48.33% qualified as AI at T0 ≤ 24 µg/dL, 61.67% at delta cortisol (∆ = T30-T0) ≤7 µg/dL, and 78.33% at ∆ ≤9 µg/dL. Using receiver operating characteristic curve, the area under the curve (AUC) was 0.4954, signifying poor prediction to death. Conclusions: Indians have completely different characteristics of cortisol levels in sepsis patients, in comparison to the Western data. They have higher range of basal cortisol levels, higher percentage of AI, and an inability to predict mortality with the cortisol levels. Hence, there is requirement of an international study to confirm the dichotomy of the results.
Non-alcoholic Fatty Liver Disease (NAFLD) is currently reliably and increasingly being diagnosed ... more Non-alcoholic Fatty Liver Disease (NAFLD) is currently reliably and increasingly being diagnosed and classified by non-invasive methods in comparison with standard invasive methods. Various permutations and combinations has been studied and explored with different clinical sign and symptoms with or without lab profiles to closely approach the precise diagnosis. It is indeed the need of the hour to understand the most suitable non-invasive clinical modality in a given set of patient profile to reach to the finest and closest diagnosis without compromising the outcome as far as the patient management is concerned. This could well be learnt progressively to more and more effectively use of these non-invasive tools and avoiding cumbersome liver biopsy in parallel Fatty liver is frequently used terminology in the day to day reporting of routine and focused abdominal imaging. This leaves a good amount of stress and alarm on patients and their kin's mind. The most frequently asked question after these reports is 'what is the current status and what next ?' Various clinical methods extending from a single parameter to combination of various clinical laboratory profile has been tried to answer the question precisely. There are a lot of scores and system which exists in the literature but 'which one to use and where to use' is sporadically arranged making it difficult in usability. This is to simplify the same and make better understanding of the topic for the clinicians to objectively answer all the queries related to stage, grade and diagnose of this entity. Furthermore it is attempted to reliably use the non-invasive modalities of staging and grading to replace cumbersome liver biopsy without compromising the clinical benefits out of management dependent on these parameters. CONVENTIONAL METHODS NAFLD should strongly be suspected in patients with deranged liver enzymes and/or who have features of metabolic syndrome. However, before labelling a person as NAFLD extensive/detail history (alcohol abuse, drug intake) must be taken and serological studies (viral and autoimmune hepatitis, alpha-1-antitrypsin deficiency, hemochromatosis and Wilson's disease) should be done.
Dear Editor, Overlap syndrome (OS) is an uncommon rheumatological condition wherein there is an o... more Dear Editor, Overlap syndrome (OS) is an uncommon rheumatological condition wherein there is an occurrence of two or more well-defined connective tissue diseases (CTDs) at the same or at different times in the same patient. 1 While OS is most often described in association with systemic sclerosis, that involving idiopathic inflammatory myopathies (IIMs) are uncommon. Primary vasculitides were not encompassed in the above definition of OS until the publication of a few recent case reports. 2 Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) overlapped with IIM is even more rare. To the best of our knowledge, only two case reports of an overlap of AAV with dermatomyositis (DM) exist. There is a lack of such overlap cases in the children.
SUMMARY The approach to an intrinsic cause of superior vena cava syndrome (SVCS) is usually diffi... more SUMMARY The approach to an intrinsic cause of superior vena cava syndrome (SVCS) is usually difficult but rewarding. We report a case of a middle-aged man who presented with progressive oedema of the upper half of the body, dyspnoea, cough and weight loss for a 1-year duration. He was a non-smoker without prior hospitalisation. Chest radiography showed right-sided pleural effusion with an apparent normal superior mediastinum. Contrast-enhanced CT of the chest revealed a right atrial mass extending and completely obliterating to superior vena cava. The differentials were tuberculosis, invasive fungal granuloma, sarcoidosis, primary vasculitis, chronic venous thrombosis, cardiac sarcoma/lymphoma and metastatic thyroid tumour or thymoma. He underwent transvenous (femoral approach) biopsy of the mass and then cardiothoracic surgery after haemodynamic instability. Pathology showed invasive thymoma type B3. This case highlights the approach to an intrinsic cause of SVCS, a complication of the transvenous approach, and importantly a noble finding of venous spread metastasis. BACKGROUND
Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly Am... more Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly America, Africa, and Asia. In India, it is being reported from most states; however, it is endemic along the Ganges belt. We report a case of an apparently immunocompetent male who presented with 3-month history of fever, cough, and weight loss with recent onset odynophagia and had hepatosplenomegaly and mucocutaneous lesions over the face. The differential diagnosis of leishmaniasis, tuberculosis, leprosy, fungal infection, lymphoproliferative malignancy, and other granulomatous disorders was considered, but he succumbed to his illness. Antemortem skin biopsy and bone marrow aspiration along with postmortem liver, lung, and spleen biopsy showed disseminated histoplasmosis. This case highlights the need for an early suspicion of progressive disseminated histoplasmosis in the presence of classical mucocutaneous lesions even in an immunocompetent patient suffering from a febrile illness. Cure rate approaches almost 100% with early treatment, whereas it is universally fatal if left untreated.
India and neighboring Nepal, Bangladesh along with Sudan and Brazil
are the four largest foci of ... more India and neighboring Nepal, Bangladesh along with Sudan and Brazil are the four largest foci of visceral leishmaniasis and account for 90% of the world’s visceral leishmaniasis (VL) burden, with India being the worst affected. High degree of suspicion is usually based on patient presenting from endemic area with features of pancytopenia hepatosplenomegaly. Hemophagocytic lymphohistiocytic (HLH) syndrome also presents with similar clinical features. Visceral leishmaniasis leading to secondary HLH syndrome is in itself a rare entity while both of these presenting in pregnant patient, to the best knowledge of the authors, is yet to be described in literature.
Drug trafficking is an international problem. Over years it has increased in prevalence and conce... more Drug trafficking is an international problem. Over years it has increased in prevalence and concealment methods. Body packers swallow wrapped packets of illicit drugs, mainly cocaine and heroin and try to conceal them from security personnel. They present to physicians either as body packer syndrome with symptoms of intoxication or asymptomatically on suspicion of drug concealment, for observation. We report a case of middle aged unknown male, found in comatose state on road side by Delhi police (India), brought to our emergency without any signs of injury. Initially organophosphate toxidrome was suspected, later confirmed to be opiod toxidrome with internal concealment of many balloons (of polythene) wrapped packets of heroin. On failure of conservative removal, he underwent laparotomy with complete removal of all the packets. He was discharged in stable condition and handed over to the police. This is the first case report of live heroin body packer syndrome from India.
The objective is to study relation of HbA1c with cardiovascular disease risk factors in non-diabe... more The objective is to study relation of HbA1c with cardiovascular disease risk factors in non-diabetic subjects of Northern-India having coronary artery diseases. This hospital based analytic-cross sectional study was conducted in department of medicine at a tertiary care center in Northern-India during the period of March-July, 2012 among 69 admitted cases of CAD. Patients with CAD and had HbA1c 4-6.4 %, FPG< 100 mg/dL (< 5.55 mmol/L) or PPPG< 140 mg/dL(7.77 mmol/L) were included in this study. Patients who had diabetes, acute febrile illness, anemia (Hb< 10 g/dL in female &< 12 g/dL in male), hemoglobinopathy and who did not give informed consent were excluded from the study. CAD was defined based on documented history of myocardial infarction or ECG criteria as per Minnesota codes. Special INTERHEART questionnaires were being used for physical activity and dietary habits. A detail history and clinical examination was carried out. HbA1c was measured by chromatography analyzer (Turbidimetric HPLC method). BMI, WC, serum TC, TG, and LDL increased significantly with higher tertiles of HbA1c similar to known cardiovascular risk factors viz. family H/O premature CAD, dyslipidemia (high TG & low HDL) and obesity, especially, central type(P for trend < 0.05).The mean ± SD HbA1c value in the study cohort was 5.39 ± 0.78%. Mean HbA1c differed statistically significantly in subjects having unhealthy diet, obesity (including central type) and hypertriglyceridemia (p < 0.05). HbA1c had significant correlation with BMI (r=+0.429, p=0.0002), WC (r=+0.4311, p=0.0002), FPG (r=+0.394, p=0.0008), TG (r=+0.4151, p=0.0004), TC (r=+0.356, p=0.0027), LDL (r=+0.290, p=0.0168), and VLDL (r=+ 0.4101, p=0.0005). On multivariate analysis, BMI (β=+0.05, p=0.007) and FPG (β=+0.04, p=0.000) were significantly correlated. When separate correlation was done with FPG as dependent variable, no risk factors were significantly correlated. In non-diabetic CAD patients, HbA1c showed significant association with CVD risk factors i.e. obesity including central type and dyslipidemia (especially hypertriglyceridemia), typical of Asian Indian phenotype. Therefore, HbA1c might be a useful measure even among the non-diabetic population in assessing an individual's cardiovascular risk.
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Papers by Prasan K Panda
are the four largest foci of visceral leishmaniasis and account for 90% of
the world’s visceral leishmaniasis (VL) burden, with India being the worst
affected. High degree of suspicion is usually based on patient presenting from endemic area with features of pancytopenia hepatosplenomegaly. Hemophagocytic lymphohistiocytic (HLH) syndrome also presents with similar clinical features. Visceral leishmaniasis leading to secondary HLH syndrome is in itself a rare entity while both of these presenting in pregnant patient, to the best knowledge of the authors, is yet to be described in literature.
are the four largest foci of visceral leishmaniasis and account for 90% of
the world’s visceral leishmaniasis (VL) burden, with India being the worst
affected. High degree of suspicion is usually based on patient presenting from endemic area with features of pancytopenia hepatosplenomegaly. Hemophagocytic lymphohistiocytic (HLH) syndrome also presents with similar clinical features. Visceral leishmaniasis leading to secondary HLH syndrome is in itself a rare entity while both of these presenting in pregnant patient, to the best knowledge of the authors, is yet to be described in literature.