Shades of Blue: A Case Series of Acquired Methemoglobinemia.

Acquired methemoglobinemia (MetHb) is a rare but potentially life-threatening condition that has varied etiology, usually toxin- or drug-induced. We had five cases of acquired methemoglobinemia during six months. Their presentation varied from an asymptomatic state to respiratory distress. The presence of cyanosis and low oxygen saturation (SpO2), despite normal partial pressure of oxygen (PaO2) and chocolate brown-colored blood, were diagnostic clues present in all cases. A high level of methemoglobinemia was detected on arterial blood gas (ABG), confirming the diagnosis. Methylene blue was used as an antidote along with supportive care in symptomatic cases. All these cases of methemoglobinemia recovered completely. A high index of suspicion for methemoglobinemia should be maintained in cases presenting with persistent hypoxia or cyanosis despite normal PaO2.

Uncovering the Unusual: A Case of Mixed Connective Tissue Disease With Rare Presentation, Atypical Complications, and Therapeutic Dilemmas.

Mixed connective tissue disease (MCTD) is an overlap syndrome characterized by features of systemic lupus erythematosus, scleroderma, and polymyositis, along with the presence of the U1RNP antibody. A 46-year-old female patient presented with severe anemia, cough, and breathlessness, and was diagnosed with cold agglutinin disease, a type of autoimmune hemolytic anemia (AIHA). Autoimmune workup revealed MCTD by positive antinuclear and U1RNP antibodies. She had bilateral miliary mottling on X-ray and a tree-in-bud appearance on high-resolution computed tomography of the thorax, which were suggestive of pulmonary tuberculosis. Standard therapy with steroids was not advisable. She was subsequently started on anti-tuberculosis treatment (anti-Koch's therapy), followed by steroid therapy and immunosuppressive therapy after three weeks. The patient responded well to treatment, but after two months, she developed cytomegalovirus (CMV) retinitis. Adult-onset CMV disease may occur as a result of primary infection, reinfection, or activation of a latent infection. Although not directly related, it can occur as an atypical association in the setting of immunosuppressive therapy. Morbidity and mortality are significantly increased in this population secondary to infectious potentiation: immunosuppression causes infections, and infections cause AIHA. The management of MCTD and secondary AIHA and immunosuppression poses a therapeutic challenge.

Effect of Ramipril on Cardiac Autonomic Neuropathy in Patients With Type II Diabetes Mellitus.

Background Cardiovascular autonomic neuropathy (CAN), an important form of DAN is caused by the impairment of the autonomic nerve fibers that innervate the heart and blood vessels and leads to abnormalities in cardiovascular dynamics. The earliest finding of CAN, even at the subclinical stage, is a decrease in heart rate variability (HRV). Objective The objective is to assess the effect of ramipril 2.5mg once daily on cardiac autonomic neuropathy in type II DM patients as an add-on to a standard antidiabetic regimen for a duration of 12 months. Materials and methods A prospective, open-label, randomized, parallel-group study was conducted on type II DM with autonomic dysfunction. Patients in Group A received tablet ramipril 2.5mg daily along with the standard antidiabetic regimen which consist of Tab Metformin 500mg twice a day and Tab Vildagliptin 50mg twice a day and group B received only the standard antidiabetic regimen for 12 months. Results Among 26 patients with CAN, 18 patients completed the study. After one year in group A, Delta HR value increases from 9.77±1.71 to 21.44±8.44 and the E:I ratio (ratio of the longest R-R interval during expiration and shortest R-R interval during inspiration) improved from 1.23±0.35 to 1.29±0.23 signifying significant improvement in parasympathetic tone. Results of the postural test showed significant improvement in SBP. Analysis of HRV by time domain method showed that the standard deviation of RR (SDRR) interval and Standard deviation of differences between adjacent RR interval (SDSD) value increased significantly in group A. Analysis of HRV frequency domain indices showed that LFP:HFP ratio improved after treatment in ramipril group indicating improvement in sympatho-vagal balance. Conclusion Ramipril improves parasympathetic component more as compared to sympathetic component of DCAN in type II DM. Ramipril could be a promising option having favorable long-term outcomes in diabetic patients especially when treatment begins at subclinical stage.

An Assessment of the Utility of Serum Fructosamine in the Diagnosis and Monitoring of Diabetes Mellitus.

BACKGROUND: Fructosamine (FA) has gained importance as a new biomarker for hyperglycemia in the past decade and may be of indispensable use in certain conditions where hemoglobin A1c (HbA1c) falls short of utility such as disorders of red blood cells, patients with rapid glycemic excursions requiring more short-term monitoring, pregnancy, chronic kidney disease, etc. Methods: The present study was a hospital-based observational cross-sectional study conducted in the Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Nagpur, India. Serum HbA1c, FA, albumin-corrected fructosamine (AlbF), total protein-corrected FA (PrF), hemoglobin (Hb), and hematocrit (Hct) were estimated in 32 controls (Group I) and 32 cases of diabetes mellitus (DM) (Group II). The clinical data and lab results were presented as mean±SD/±standard error (SE) of the mean. Student's t-test and ANOVA were used to compare various parameters between the groups. Pearson correlation analysis was performed to assess the correlation between different diagnostic parameters. The receiver operating characteristic (ROC) curve was plotted to assess the diagnostic significance and cut-off value for FA, AlbF, and PrF. RESULTS: The controls and cases were matched for age and gender distribution. Serum HbA1c (p<0.0001), serum FA (p<0.0001), fasting blood sugar (p=0.001), postprandial blood sugar (p<0.0001), random blood sugar (p=0.001), hematocrit (p=0.002), AlbF (p<0.0001), and PrF (p<0.0001) were found to be significantly higher in known diabetic subjects compared to controls. The case group was further subdivided into pre-diabetic and diabetic groups. On correlation analysis of HbA1c with various parameters, a moderate correlation of HbA1c was noted with FA (r=0.522, p<0.0001) and AlbF (r=0.375, p=0.002) in all subjects. Additionally, a moderate correlation of FA (r=0.479, p=0.033), AlbF (r=0.444, p=0.050), and PrF (r=0.441, p=0.065) with HbA1c was also found in subjects with diabetic range glycemia. No such correlation was noted in the pre-diabetic group. No significant correlation was noted between FA and its corrected values in any range of glycemia. None of the parameters assessing glycemia were found to be significantly affected by hemoglobin status. On ROC curve analysis, HbA1c was found to be the best parameter (area under the curve (AUC) =83%, p<0.0001) followed by AlbF (AUC= 80.5%, p<0.0001) and uncorrected FA (AUC=80.5%, p<0.0001) to diagnose DM. CONCLUSION: Serum FA should be considered a valid diagnostic biomarker and of indispensable use in special populations where HbA1c falls short of utility such as patients with red blood cell disorders or those showing rapid glycemic excursions such as those on corticosteroid therapy or insulin therapy, etc. It exhibits additional advantages over HbA1c with respect to lower reagent cost and easy automation on any conventional laboratory instruments based on simple colorimetry.

Neutrophil-to-Lymphocyte Ratio as a Predictor of Disease Severity and Mortality in Coronavirus Disease 2019: Prospective Study From Central India.

BACKGROUND: Clinical presentation of coronavirus disease 2019 (COVID-19) varies from an asymptomatic state to severe disease characterized by acute respiratory distress syndrome, respiratory failure, thrombosis, and multi-organ dysfunction syndrome. The neutrophil-to-lymphocyte ratio (NLR) has been reviewed as one of the laboratory factors that have been proposed to predict the severity of disease and mortality in COVID-19 pandemic. AIM AND OBJECTIVES: To evaluate the association between NLR and the disease severity and mortality in COVID-19. MATERIALS AND METHODS: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in a tertiary-care teaching medical institute of Central India. COVID-19 patients of the age group 18 years and above admitted during the study period were included. Cases were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. NLR was calculated by doing a complete blood count at the time of hospitalization by the Mindray BC-6000 auto hematology analyzer. The outcome of the disease was classified as recovery and death during hospitalization. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of NLR at admission to predict severe COVID-19 or mortality. Ordinal regression analysis was used to assess the impact of NLR on disease severity and mortality. RESULTS: Mean NLR was significantly higher in the severe COVID-19 group as compared to the mild/moderate group and in deceased as compared to discharged cases. ROC curve analysis revealed NLR to be an excellent predictor of disease severity as well as a prognostic parameter for risk of death. NLR was found to be a significant independent positive predictor for contracting the severe disease (Odd's ratio 1.396, 95% CI=1.112-1.753, p=0.004) and mortality (Odd's ratio 1.276, 95% CI=1.085-1.499, p=0.003). CONCLUSION: High NLR was significantly associated with the disease severity and mortality in COVID-19.