Pharmaco-invasive Therapy with Fibrinolytic Agents: A Potent Lifesaving Reperfusion Strategy in STEMI Patients in Metro/Tier-I Cities in India.

Background: Primary Sjogren's Syndrome (pSS) with Hypokalemic Periodic Paralysis(HPP) whether an association or a different clinical subset needs review. Aim: To generate a consensus on the importance of pharmaco-invasive therapy for STEMI patients when primary PCI cannot be expeditiously performed in metro and tier-I cities in India. Methodology: A total of 8 expert panel groups comprising 48 experts from Cardiology specialty in India were convened. These groups individually reviewed the evidence on various types of fibrinolytic agents, their importance in STEMI management in general and in India and finally shared their experience and views on the importance of pharmaco-invasive therapy during STEMI management in metro and tier-I cities in India. Individual group opinions were compiled into one document and the consensus was finalized after it was approved by all panel members. Results: The board concluded that in metro and tier-I cities, pharmaco-invasive therapy, preferably using third generation fibrinolytic agents such as Reteplase and Tenecteplase, should be instituted to all patients for whom a delay in primary PCI of greater than 120 minutes from the time of ECG confirmation is anticipated. This will enhance the time window to preserve the myocardium from further damage arising due to patient related, transportation related or in- hospital delays. The present article also highlights the importance of third generation fibrinolytics in pharmaco-invasive therapy and looks at strategies to augment their use. Conclusion: Pharmaco-invasive therapy is recommended in STEMI patients even in metro and tier-I cities of India, where delay in access to PCI is anticipated, in place of a strategy of promoting only primary PCI.

Anti-PF4 antibodies and their relationship with COVID infection.

Detecting anti-PF4 antibodies remains the golden diagnostic method for heparin-induced thrombocytopenia (HIT) diagnosis with high sensitivity and specificity. Various lab tests detect anti-PF4 antibodies, including immunoassays and functional assays. Even with positive detection of the anti-PF4 antibody, several factors are involved in the result. The concept of anti-PF4 disorders was recently brought to light during the COVID pandemic since the development of vaccine-induced thrombotic thrombocytopenia (VITT) with the adenovirus-vectored-DNA vaccine during the pandemic. Circumstances that detect anti-PF4 antibodies are classified as anti-PF4 disorders, including VITT, autoimmune HIT and spontaneous HIT. Some studies showed a higher percentage of anti-PF4 antibody detection among the population infected by COVID-19 without heparin exposure and some supported the theory that the anti-PF4 antibodies were related to the disease severity. In this review article, we provide a brief review of anti-PF4 disorders and summarize the current studies of anti-PF4 antibodies and COVID-19 infection.

Leprosy with Guillain Barre Syndrome: a new neurologic manifestation?

A 19-year-old female patient of lepromatous leprosy with Type II reaction, on multidrug therapy and prednisolone, presented with acute onset flaccid quadriparesis. The cerebrospinal fluid examination revealed albumino-cytologic dissociation. Nerve biopsy showed infiltration with lepra bacilli, features of vasculitis, and demyelination. There were no other identifiable precipitating factors for Guillain Barre Syndrome in this patient. Her condition improved without any steroid therapy. This case emphasizes the hypothesis that cell injury caused by Type II reaction can expose neural antigens and incite an autoimmune reaction in the form of Guillain Barre Syndrome.

Pigmentation: a potential cutaneous marker for AIDS?

Pigmentation of skin, nails and mucosae has frequently been described in HIV positive patients. Various causes for this phenomenon have been ascribed, which include intake of various drugs like zidovudine, opportunistic infections like toxoplasmosis and adrenocortical suppression. However, there has been no uniform explanation. We describe three AIDS patients with different personal and disease profiles but essentially the same pattern of pigmentation. This pattern of pigmentation is thereby discussed. We also propose that this pigmentation could be a result of late stage HIV disease per se and thus could serve as a useful cutaneous marker for the same.

Nephrotic syndrome as a complication of intravesical BCG treatment of transitional cell carcinoma of urinary bladder.

Nephrotic syndrome can be associated with various neoplasms, especially solid tumors and lymphomas. This patient presented with painless hematuria of transitional cell carcinoma of urinary bladder, underwent transurethral resection, but developed recurrence 16 months later. Repeat resection was done and intravesical Bacillus Calmette-Guerin (BCG) injections were started. After six months, the patient developed hypertension and nephrotic syndrome with a biopsy revealing membranous glomerulonephritis, though there was no radiological evidence of tumor. This is the first case of nephrotic syndrome with intravesical BCG instillation in a bladder carcinoma patient.

Concomitant congenital, atherosclerotic coronary and peripheral artery disease: managed with percutaneous interventions.

Coexistence of both congenital and atherosclerotic coronary heart disease is rare. We report a 52-year-old man who had severe valvular pulmonic stenosis and significant atherosclerotic disease involving coronary, subclavian and renal arteries. This combination of congenital heart disease and atherosclerotic arterial disease is probably the first report in published English literature. He underwent successful staged percutaneous interventions, which included balloon pulmonic valvuloplasty and angioplasty and stenting of right renal, left subclavian and right coronary arteries. On follow-up at 8 months, a check angiogram revealed patent stents and insignificant gradient across pulmonic valve.

Psoriatic nephropathy--does an entity exist?

Psoriasis is an immune-mediated chronic inflammatory disorder of the skin. Association with kidney disease has been debated for a long time. Secondary renal amyloidosis in psoriatic arthropathy and drug-induced renal lesions secondary to methotrexate or cyclosporine are accepted accompaniments of psoriasis. IgA nephropathy is also known to occur in psoriatics. We report three interesting cases of renal involvement in long-standing established psoriasis on topical therapy alone. The patients presented with hypertension, significant proteinuria, hypoalbuminemia, and dyslipidemia. Kidney biopsies revealed "mesangioproliferative glomerulonephritis with IgA nephropathy," "focal proliferative glomerulonephritis," and "membranous glomerulonephropathy." The former two had marked active urinary sediment. Patients improved on prednisolone and angiotensin-converting enzyme inhibitors. Contrary to the belief that renal involvement in psoriasis is coincidental, we propose that kidney disease may be a common accompaniment of psoriasis, which may be labeled as "psoriatic nephropathy" or "psoriatic kidney disease." The exact mechanism of this entity is yet to be elucidated.

Aplastic anemia complicating systemic lupus erythematosus: successful management with cyclosporine.

Anemia is common with connective tissue disorders, but pancytopenia is rare. We report a 22-year-old female who presented with menorrhagia, seizures, anemia, leukocytosis, thrombocytopenia, pericardial effusion, positive ANA, and evidence of vasculitis on CT head scan and was diagnosed with systemic lupus erythematosus (SLE). After 7 months of remission, she was readmitted with menorrhagia and pancytopenia. Investigations revealed aplastic anemia. She survived on transfusion support for 6 weeks, during which period she received methylprednisolone and cyclophosphamide pulses, and phenytoin was omitted but to no avail. Cyclosporine (300 mg/day) was started and the aplastic anemia responded. After 4 months of therapy, the cyclosporine was gradually tapered over the next 2 months. The patient has been on 10 mg/day of prednisolone for the last 6 months. Aplastic anemia is rare in SLE and the response to immunosuppressants is variable, but here is a success story.