Impact of prior antibiotic use in culture-negative endocarditis: review of 86 cases from southern Pakistan.

BACKGROUND: A large number of patients treated at our hospital for endocarditis have negative cultures. Taking into consideration the fact that many of these patients receive antibiotics prior to referral, we decided to study culture-negative endocarditis in Pakistan. METHODS: The medical records of all patients admitted to the Aga Khan University Hospital, Pakistan, for the period from 1988 to 2001, with an underlying diagnosis of infective endocarditis (IE) and negative cultures, were reviewed. RESULTS: Of the 159 patients diagnosed with IE by revised Duke criteria, 86 (54.1%) had persistent negative cultures. More than half of these patients (52%) had received antibiotics before being referred to our center. Patients with culture-negative endocarditis were less likely to be classified as definite endocarditis by revised Duke criteria (p<0.001, 95% CI 0.07-0.3) or to have large vegetations (p=0.021, 95% CI 0.05-0.5), and more likely to have a mitral valve prolapse (p=0.003, 95% CI 1.6-2.3). Definite endocarditis (p=0.042, 95% CI 1.02-7.4), heart failure (p=0.008, 95% CI 1.4-12.7), renal failure (p=0.017, 95% CI 1.16-40.7), embolism (p=0.019, 95% CI 1.2-38.8), and neurological complications (p=0.02, 95% CI 1.16-9.2) were associated with an increased mortality. CONCLUSION: Culture-negative endocarditis is very common among patients with IE in Pakistan. The presentation, laboratory findings, and complications are similar to those for culture-positive endocarditis. It is postulated that previous antibiotic treatment is the most common cause of culture-negative endocarditis in our hospital.

Clinical presentation and outcome of autosomal dominant polycystic kidney disease in Pakistan: a single center experience.

OBJECTIVE: To delineate clinical presentation and outcome of Autosomal Dominant Polycystic Kidney Disease (ADPKD) in terms of need for renal replacement therapy of kidney transplantation in Pakistani patients. METHODS: Patients with ADPKD were identified using strict clinical criteria. Medical charts were evaluated retrospectively for initial presenting complaints, co-morbids, family history of ADPKD, any palpable mass on abdominal examination, cardiac examination for any abnormal finding and use of any anti-hypertensive drugs. Laboratory parameters were assessed. Chi square and Logistic regression analyses at 95% CI were used for statistical significance. A p value of less 0.05 was considered statistically significant. RESULTS: A total of 56 patients fulfilled our criteria of ADPKD. There were 40 (71.4%) males and 16 (28.6%) females in our study. The mean age at the time of diagnosis of ADPKD was 47.0 +/- 14.5 years. Mean follow up period for all patients was 7.6 +/- 4.2 years. Most common form of presentation was hypertension in 38 (67.9%) patients. Kidneys were palpable in 33 (58.9%), liver in 16 (28.6%) and spleen in 6 patients (10.7%). Microscopic haematuria was observed in 38 (67.8%) patients while gross haematuria was present in 10 (17.9%) patients. The murmur of mitral valve prolapse was found in 10 patients on clinical examination which was later confirmed on transthoracic echocardiography (TEE). On MRI/MRA 2 (3.6%) patients each had berry aneurysm and AV malformations. Three patients (5.4%) received renal transplant and 19 (33.9%) patients were dialysis dependent at the end of study. A total 11 (20%) were lost to follow up. Two patients (3.5%) died during six years follow up. Male sex and uncontrolled hypertension were most important predictors of poor prognosis (p < 0.03 and < 0.048 respectively). CONCLUSION: Pre-symptomatic patients with ADPKD should be monitored with blood pressure measurements and assessment of their renal function. The advantages of such monitoring include the ability to prevent or control infection and hypertension, to identify potential kidney donors from among the family, to offer advice on marriage and childbearing, and to provide prenatal diagnosis.

Etiology of acute renal failure in a tertiary center.

Acute renal failure (ARF) occurs commonly in developing countries. Our aim was to assess the etiologies and outcomes of ARF in a tertiary care hospital in Pakistan and compare them with data from developed and developing countries. All patients admitted to the Aga Khan University Hospital, Karachi from January 1991 to December 2000 fulfilling the criteria of acute renal failure were reviewed retrospectively. Acute renal failure for the purpose of this study was defined as persistent elevation of serum creatinine to above 2 mg/dL (177 umol/L) on two consecutive occasions despite correction of any abnormal hemodynamic or mechanical factors. We studied 898 patients fulfilling the criteria of ARF, 61% (551) were males, and the mean age was 53% +/- 17.6 (range 15-91) years. Medical causes accounted for (88%) of ARF cases and surgical causes for (11%). Majority of the patients had pre-renal ARF, and 5% had drug related ARF. The base line creatinine was 1.9 +/- 1.8 mg/dL, while 27% of the patients had pre-existing chronic kidney disease. The mean rise in creatinine was 7.18 +/- 3.8 mg/dL. We conclude that ARF resulted from pre-renal etiologies in majority of the patients and early recognition and management may improve the prognosis of these potentially preventable causes.

Static pulmonary nodules from thyroid malignancy.

Papillary carcinoma of thyroid tends to be indolent. This is an unusual case of papillary carcinoma of thyroid with asymptomatic pulmonary metastasis for more than a decade, finally presenting with mild respiratory symptoms in a 21-year-old female. Fine needle aspiration and cytology (FNA-C) of a nodule in the lungs revealed features consistent with a papillary carcinoma of thyroid. Confirmed on thyroidectomy specimen. She subsequently received Iodine-131 (I131). A follow-up radio-iodide scan, 48 hours after, revealed diffuse uptake within the lung parenchyma. With static nodular shadowing on radiograph, a metastatic origin, in particular that of the thyroid, should be considered. I131 scintigraphy can help support the diagnosis of carcinoma of thyroid.

Total parotidectomy under local anesthesia: a novel technique.

Parotidectomy is a common procedure usually done for a parotid mass necessitating a histological diagnosis. Operation is normally performed under General anesthesia with a nerve stimulator to facilitate facial nerve stimulation. We describe a new technique with reports of three cases, making total parotidectomy under local anesthesia possible. The ascending cervical branch of cervical plexus and the auriculotemporal nerve were anesthetized by bupivacaine 0.25% (2mg/kg) and lignocaine with adrenaline 7 mg/kg. Effective onset of anesthesia was within 15-25 minutes and the operations lasted between 2-3 hours without any complications. This offers advantage in high-risk patients where general anesthesia is contraindicated. The facial nerve can be easily identified with on command movements by the patient rendering the use of nerve stimulator or injection of the dye superfluous. This technique makes total parotidectomy an outpatient procedure and facilitates an early discharge.

Do clinical manifestations of Systemic Lupus Erythematosus in Pakistan correlate with rest of Asia?

OBJECTIVE: Systemic Lupus Erythematosus (SLE) is known to be different among people with different racial, geographical and socio-economic back grounds. Asia has diverse ethnic groups broadly, Orientals in the East and Southeast Asia, Indians in South Asia and Arabs in the Middle East. These regions differ significantly from the Caucasians with reference to SLE. The purpose of this study was, therefore, to delineate the clinical pattern and disease course in Pakistani patients with SLE and compare it with Asian data. METHODS: Patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association admitted at the Aga Khan University Hospital between 1986 and 2001 were studied by means of a retrospective review of their records. The results were compared with various studies in different regions of Asia. RESULTS: Demographically, it was seen that SLE is a disease predominantly of females in their third decade, which is generally consistent with Asian data. There was less cutaneous manifestations, arthritis, serositis, haematological and renal involvement compared to various regions in Asia. The neurological manifestations of SLE, however, place Pakistani patients in the middle of a spectrum between South Asians and other Asian races. CONCLUSION: This study has shown that the clinical characteristics of SLE patients in our country may be different to those of other Asian races. Although our population is similar to South Asians, but clinical manifestations of our SLE patients are considerably different, suggesting some unknown etiology. Further studies are required to confirm the above results and to find statistically sounder associations.

Renal involvement in systemic lupus erythematosus in Pakistan.

OBJECTIVE: To find the prevalence of lupus nephritis, delineate its clinical, immunological and therapeutic characteristics and compare them with the data worldwide. PATIENTS AND METHODS: Between 1985 and 2001, 198 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association (ARA) admitted to the hospital were studied by means of a retrospective review of their records. RESULTS: Renal involvement was found in 89 (45%) patients. Biopsy showed lupus nephritis in 42 patients; there were 9 male and 33 females. Mean age at initial presentation was 27 years and mean duration of follow-up was 2 .3 years. The histological types (WHO Classification) were mainly class. 4 (n = 27), class 3 (n = 7) and class 5 (n = 6). Immunoflourescence showed a predominantly granular pattern of IgG, IgA and C3. Renal manifestations included renal failure (50%), microscopic hematuria (67%), active urine sediment (22%), and proteinuria (74%). Proteinuria was nephrotic range in 45% patients. Treatment was with combinations of prednisolone and cyclophosphamide (n = 13), prednisolone and azathioprine (n = 27). 19 patients received high dose methyl prednisolone (1 gm/day for 3 days). There was no difference in mortality rate between prednisolone and cyclophosphamide and prednisolone and azathioprine treatment groups. The overall mortality rate was 17% (n = 7). Mortality was higher in WHO class 4 and 5 as compared to class 2 and 3 (p < 0.001). CONCLUSION: The prevalence of lupus nephritis in our population is an intermediate between Caucasians and other Asians. Certain clinical characteristics in our patients with lupus nephritis are different as compared to various other studies. Because of limited resources for treatment in developing countries, we believe that patients with lupus nephritis should be treated with improved ancillary medical therapies and more effective immunosuppressive regimens.