Scrub typhus: A prospective, observational study during an outbreak in Rajasthan, India.

BACKGROUND: Scrub typhus, a potentially fatal rickettsial infection, is common in India. It usually presents with acute febrile illness along with multi-organ involvement caused by Orientia tsutsugamushi. As there was an outbreak of scrub typhus in the Hadoti region of Rajasthan and there is a paucity of data from this region, we studied this entity to describe the diverse epidemiological, clinico-radiological, laboratory parameters and outcome profile of patients with scrub typhus in a tertiary care hospital. METHODS: In this descriptive study, we included all patients with an acute febrile illness diagnosed as scrub typhus by positive IgM antibodies against O. tsutsugamushi, over a period of 4 months (July to October 2014). All relevant data were recorded and analysed. RESULTS: A total of 66 (24 males/42 females) patients were enrolled. Fever was the most common presenting symptom (100%), and in 67% its duration was for 7-14 days. Other symptoms were breathlessness (66.7%), haemoptysis (63.6%), oliguria (51.5%) and altered mental status (39.4%). The pathognomonic features such as eschar (12%) and lymphadenopathy (18%) were not so common. The commonest radiological observation was consistent with acute respiratory distress syndrome. Complications noted were respiratory (69.7%), renal (51.5%) and hepatic dysfunction (48.5%). The overall mortality rate was 21.2%. CONCLUSIONS: Scrub typhus has emerged as an important cause of febrile illness in the Hadoti region and can present with varying clinical manifestations with or without eschar. A high index of suspicion, early diagnosis and prompt intervention may help in reducing the mortality.

A Case of Peeling Skin Syndrome.

Peeling skin syndrome is a very rare autosomal recessive disease characterized by widespread painless peeling of the skin in superficial sheets. Etiology is still unknown with an autosomal recessive inheritance. Less than 100 cases have been reported in the medical literature. We present a 32-year-old man having asymptomatic peeling of skin since birth. Sheets of skin were peeling from his neck, trunk, and extremities, following friction or rubbing especially if pre-soaked in water but sparing palm and soles. Histologically, there was epidermal separation at the level of stratum corneum, just above the stratum granulosum. This case is being presented due to its rarity.

Spectrum of clinico-pathological changes in Barrett oesophagus.

OBJECTIVES: Barrett oesophagus is replacement of squamous epithelium to specialised intestinal metaplasia. It is associated with an increased risk for adenocarcinoma which develops through dysplasia. The aim of this retrospective study was to determine the relative age of occurrence and incidence of dysplasia in this part of our country. METHODS: Between January 1999 and June 2002 we diagnosed 13 cases of Barrett oesophagus. Sections were stained with routine H and E and special stain alcian blue (AB)--PAS at pH 2.5. RESULTS: Out of 55 patients with symptoms of gastro-oesophageal reflux disease, 13 cases were diagnosed as Barrett oesophagus. There were 8 males and 5 females. Majority of the patients (77%) were between 20-40 years of age. At endoscopy, in 84.6% patients, lesions were in the form of islands of red mucosa. On histology examination, in 6 cases, squamous epithelium was replaced by intestinal epithelium containing goblet cells and in 7 cases it was replaced by gastric epithelium. Associated dysplasia was not seen in any of the case, while one case showed associated adenocarcinoma. CONCLUSION: Barrett oesophagus is seen in a younger population amongst Indians. A male predominance is noted, but is not as high as reported in Western literature. There is a paucity of patients with pure dysplasia in Barrett metaplasia. Despite the fact that there are a number of patients presenting with Barrett esophagus and carcinoma, very few patients present with dysplasia, indicating that Barrett oesophagus is a silent disease presenting later as a carcinoma.

Hepatobiliary cystadenoma with mesenchymal stroma--a case report.

Hepatobiliary cystadenoma with mesenchymal stroma (HCMS) is a rare lesion characterized by multiloculated cyst lined by columnar epithelium ad mesenchymal stroma. It occurs exclusively in females and is intrahepatic in location with only 17% cases arising in extrahepatic biliary tree. Exact histogenesis is not known, but it is hypothesized the HCMS arises from ectopic embryonic tissue destined to form the adult gall bladder. HCMS has got a malignant potential and requires radical excision.

Tubercular osteomyelitis of calcaneum bone: A rare occurrence.

In spite of the endemic nature of tuberculosis in India, skeletal tuberculosis is relatively infrequent. Involvement of foot bones is uncommon and isolated calcaneum is even rarer. Osteoarticular tuberculosis is a diagnostic enigma, as the characteristic signs and symptoms of this disease may be absent, or mimic other disorders, leading to emergence of complications and therapeutic delay, particularly when the disease affects unusual sites. Here, we are reporting the case of 20-year-old male, who presented with a rare localization of tubercular osteomyelitis involving the calcaneum without adjacent joint involvement to draw attention to this exceptional location in adults, managed with anti-tubercular treatment and gained excellent recovery.

Add-on prednisolone in the management of cervical lymph node tuberculosis.

Studies defining role of systemic steroids in routine management of cervical lymph node tuberculosis (CLNTB) are too few and inconclusive. The present study was carried out to define the role of add-on prednisolone in the management of CLNTB. Patients of CLNTB were randomized into two groups. Group I patients received DOTS Category I treatment along with prednisolone 1mg/kg for first 4 weeks and then tapered down. Group II patients received DOTS Category I treatment along with placebo. Patients were kept under close follow up for 6 months. Response to therapy and adverse drug reactions, if any, were recorded. A total of 120 patients completed the study protocol. The two groups were similar with respect to age, sex, smoking, alcoholism, and clinical profile (p>0.5). At 2 months, 54 out of 60 patients in Group I showed symptom relief when compared with 44 out of 60 patients in Group II (p<0.001). Abscess, sinus, and/or appearance of new lymph node/s were noted in 3 and 13 patients in Group I and Group II, respectively (p<0.001). Complete resolution was seen in 57 patients in Group I when compared with only 40 patients of Group II and sequel in form of residual LN was noted in three patients of Group I when compared with 20 in Group II (p<0.001). Gastrointestinal side effects were reported by higher number of patients in Group I but skin rashes and joint pain were fewer when compared with Group II (p>0.05). All the adverse reactions were transient and amenable to symptomatic treatment.

Invasive pulmonary aspergillosis presenting as thoracic mass causing obstruction of the superior and inferior vena cava in an immunocompetent patient: a diagnostic dilemma.

Invasive pulmonary aspergillosis (IPA) is a disease of immunocompromised patients, but its prevalence is increasing in immunocompetent persons. Patients usually present with non-specific symptoms, sometimes consistent with bronchopneumonia. We discuss the case of a 19-year-old boy who presented with constitutional respiratory symptoms along with signs of obstruction of the superior and inferior vena cava. A chest radiograph was suggestive of a thoracic mass raising suspicion of bronchogenic carcinoma/ benign mass, sarcoidosis and tuberculosis, but a diagnosis of invasive aspergillosis was established. The patient showed excellent clinico-radiological improvement with administration of voriconazole. Invasive pulmonary aspergillosis may also present with atypical findings and should be considered in differentials when investigating a case even if the patient does not have a risk factor.