Metformin-Induced Chronic Diarrhea Misdiagnosed as Irritable Bowel Syndrome for Years.

Metformin is the most prescribed and recommended drug for type 2 diabetes mellitus because of its better tolerability, pleiotropic benefits, and cost-effectiveness. Metformin inhibits hepatic glucose production and increases muscle glucose uptake. Metformin is also associated with gastrointestinal side effects like abdominal bloating, flatulence, diarrhea, nausea, and vomiting. Metformin-related gastrointestinal side effects are mainly due to alteration in gut microbiota, raised intestinal glucose, and increased ileal bile salt reabsorption. We report a case of a 62-year-old diabetic patient who presented with chronic diarrhea with a weight loss of 6 kg from the last six years after initiation of metformin. He underwent multiple investigations and was finally misdiagnosed with irritable bowel syndrome for years. After discontinuation of metformin, there was a significant improvement in gastrointestinal symptoms. Our case highlights the importance of metformin-induced chronic diarrhea if no other causes for the diarrhea are obvious in patients with type 2 diabetes taking metformin. Consideration of this potential side effect of metformin must be valuable to avoid unwarranted investigations, additional drug therapy, and annoyance of the patients.

A Composite Study of Coagulation Milieu in Covid-19: Experience from a Tertiary Care Centre from India.

BACKGROUND: The understanding of pathogenesis is necessary for the development of effective treatment for COVID-19. Various studies have postulated that there is a complex interplay of mediators of coagulation and inflammation responsible for the pathogenesis of COVID-19. We did this study on coagulation parameters and inflammatory markers and their effect on outcome in patients with COVID-19. METHODS: This was a single centre observational cross-sectional study. Procoagulants [Prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, lupus anticoagulant (LA), fibrinogen, factor-VIII (F-VIII)]; anticoagulants [protein-C (PC), protein-S (PS), antithrombin] and inflammatory markers [interleukin-6 (IL-6) and highly sensitive - C-reactive protein (hs-CRP)] were measured at the time of hospitalization and correlated with the severity of the disease. RESULTS: A total of 230 patients were enrolled, of which 61.3%, 20.0%, and 18.7% had asymptomatic/ mild, moderate, or severe disease, respectively. COVID-19 disease severity was associated with rising trends with coagulation parameters (PT, APTT, D-Dimer; p value 0.01, <0.0001, <0.0001, respectively). Falling trends of anticoagulant (PC, Antithrombin; p value <0.0001, 0.003 respectively) and rising trends of procoagulant (fibrinogen, F-VIII; p value 0.004, <0.0001 respectively) were observed with increasing COVID-19 disease severity. Multivariate logistic regression analysis found that advanced age, high D-Dimer, and high hs-CRP (p value 0.035, 0.018, <0.0001 respectively) were independent predictors of mortality in COVID-19. Procoagulant parameters (D-dimer, APTT, Factor VIII) were positively correlated with anticoagulant parameters (PC and PS) and inflammatory parameters (hs-CRP). CONCLUSION: This study revealed increased levels of coagulation and inflammatory parameters, which correlated with the severity of COVID-19. Age, D-dimer, IL-6, hs-CRP, APTT, fibrinogen, and Factor VIII were significantly higher in patients with moderate and severe disease as compared to asymptomatic/mild disease. Advanced age, high D-dimer, and high hs-CRP were significantly associated with poor outcomes.

Rapidly Developing Cataract in Young Adult Patients: Always a Matter for Further Evaluation.

A cataract in the young age group is uncommon and it is usually secondary to eye trauma, intraocular inflammation, uncontrolled diabetes mellitus, and hypoparathyroidism. We report a case of a rapidly developing cataract over two years in a 21-year-old female with extensive intracranial calcification due to primary hypoparathyroidism. Chronic hypocalcemia due to underlying hypoparathyroidism results in cataract. Extensive bilateral intracranial calcification involving basal ganglia and white matter has been rarely reported in the literature. It occurs due to the chronic deposition of calcium-phosphorus complexes. We would like to highlight that cataract in young patients is always a matter for further evaluation. Clinicians and ophthalmologists should be aware of hypoparathyroidism as a cause of bilateral cataracts. Early diagnosis of primary hypoparathyroidism can save patients from many complications.

Post-Discharge Prophylactic Anticoagulation in COVID-19 Patients: A Clinical Dilemma.

BACKGROUND: COVID-19 pandemic has taken a great toll on the health care system worldwide. Along with the pandemic, there is also a concern regarding post COVID-19 complications in recovered patients. Thromboembolism (TE) has been reported as a fatal complication in recovered patients with COVID-19. There is still a great dilemma in post-discharge TE prophylaxis and its long-term benefits. CASE DESCRIPTION: We reported three cases of post COVID-19 with complications related to both diseases as well as post discharge anticoagulant therapy. The first case is about a 60-yr-old male who developed Covid-19 pneumonia (moderate disease) and was discharged on rivaroxaban after initial improvement. 3 weeks later, the patient was readmitted with lower gastro-intestinal bleeding. The other two cases developed pulmonary thromboembolism within a span of 2-3 months (after recovered from COVID-19 pneumonia). Both these patients were not prescribed anticoagulants for TE prophylaxis. CONCLUSION: There is an imperative need for effective guidelines for post discharge TE prophylaxis in COVID-19.

Prevalence of Asymptomatic Cryptococcal Antigenemia and Association with Follow-up Risk of Cryptococcal Meningitis and Mortality among HIV Infected Patients in North West India: A Prospective Cohort Study.

OBJECTIVE: Cryptococcal meningitis is an important cause of morbidity and mortality in HIV infected individuals. In the era of universal antiretroviral therapy, the incidence of immune reconstitution inflammatory syndrome (IRIS) related cryptococcal meningitis has increased. Detection of serum cryptococcal antigen in asymptomatic PLHIV (People Living With HIV) and preemptive treatment with fluconazole can decrease the burden of cryptococcal disease. We conducted this study to find the prevalence of asymptomatic cryptococcal antigenemia in India and its correlation with mortality in PLHIV. METHOD AND MATERIALS: This was a prospective observational study. HIV infected ART naïve patients with age of ≥ 18 years who had CD4 counts ≤ 100 /µL were included and serum cryptococcal antigen test was done. These patients were followed for six months to look for the development of Cryptococcal meningitis and mortality. RESULTS: A total of 116 patients were analyzed. Asymptomatic cryptococcal antigenemia was detected in 5.17% of patients and is correlated with increased risk of cryptococcal meningitis and mortality on follow-up in PLHIV. CONCLUSION: Serum cryptococcal antigen positivity is correlated with an increased risk of Cryptococcal meningitis and mortality in PLHIV. We recommend the screening of asymptomatic PLHIV with CD4 ≤ 100/µL for serum cryptococcal antigen, so that pre-emptive treatment can be initiated to reduce morbidity and mortality.

Role of Pigtail Catheter Drainage Versus Percutaneous Needle Aspiration in the Management of Liver Abscess: A Retrospective Analysis.

Introduction A liver abscess is an important health concern in tropical countries. Effective management of liver abscesses includes appropriate antibiotics and drainage of the abscess cavity. Percutaneous abscess drainage by pigtail catheterization is now gaining popularity. We analyzed the role of pigtail catheter drainage over percutaneous aspiration in the treatment of liver abscesses. Methods and material This was a retrospective analytical study conducted in a tertiary care center in western India. Patients of age ≥ 18 years admitted with the diagnosis of liver abscess were included in this study. To find the effectiveness of different treatment modalities, data were analyzed in three groups: Group A (Conservative treatment), Group B (Percutaneous needle aspiration), and Group C (Pigtail catheter drainage). Results A total of 64 patients with a liver abscess were analyzed. There was male predominance (93.75%). Mean abscess volume in Group C (307.9 ± 212.8 ml) was significantly higher when compared to Group A (130.8 ± 72.9 ml, p = 0.03) and Group B (177.2 ± 129.5; p = 0.024). The duration of hospital stay and residual abscess volume at the time of discharge did not show a statistically significant difference between treatment groups. Pigtail catheterization of abscesses with volume >150 ml shortened the hospital stay, whereas it prolonged the hospital stay in patients with abscess volume <150 ml. Conclusion Percutaneous pigtail catheterization would be an operative decision for the management of liver abscess. We concluded that the use of pigtail catheterization of patients with abscess volume > 150 ml improved the clinical outcome.

An open-label, randomized, 10 weeks prospective study on the efficacy of vitamin D (daily low dose and weekly high dose) in vitamin D deficient patients.

BACKGROUND: Vitamin D is an important vitamin required to maintain normal skeletal as well as nonskeletal functions. The daily supplementation of vitamin D not only have poor adherence to the regimen but also of doubtful efficacy in deficient patients. OBJECTIVES: The aim of this study was to compare the effect of oral high-dose vitamin D regimens (60,000 IU weekly) and daily low-dose vitamin D regimen of 1000 IU in mitigating symptoms and increase in serum levels of vitamin D in patients with hypovitaminosis D. MATERIALS AND METHODS: A total of 90 patients aged 18-60 years with vitamin D deficiency (serum levels < 30 ng/mL) were enrolled. A total of 38 subjects received 60,000 IU of vitamin D weekly with 500 mg/day calcium and 40 subjects received a dose of 1000 IU of vitamin D daily with 500 mg/day calcium for 10 weeks. Baseline and follow-up total serum vitamin D levels and improvement in symptoms were measured within and between groups. RESULTS: For high-dose vitamin D (60,000 IU weekly), the increase in mean serum vitamin D levels from baseline was 28.33 ng/mL over 10 weeks' treatment period; whereas for the low-dose group (1000 IU daily) the mean increment in serum vitamin D was 6.79 ng/mL for the same period. The mean difference in increase in serum vitamin D between two groups was highly significant (P < 0.001). In both the groups, decrease in myalgia as evaluated on visual analog scale was observed after 10 weeks. CONCLUSIONS: High-dose vitamin D (60,000 IU weekly) regimen rapidly normalized 25(OH) D levels and ensure symptomatic relief earlier than daily dosing of 1000 IU vitamin D for same duration.