Angioinvasive pulmonary mucormycosis presenting as multiple bilateral pulmonary nodules in a patient without obvious predisposing factors.

Pulmonary mucormycosis is a rare, frequently fatal, fungal infection. It is usually seen in the presence of various immunocompromised states, such as diabetes mellitus, haematological malignancy or renal transplantation. In the absence of underlying predisposing conditions, presentation with infiltrates, consolidation, cavitation and mass lesion have been reported. We describe a 50-year-old man who presented with cough and chest pain for six months. Chest radiograph and computed tomography showed bilateral multiple pulmonary nodules. Surgical lung biopsy revealed angioinvasive mucormycosis. He had complete recovery with amphotericin therapy.

Successful treatment of severe gastrointestinal involvement in adult-onset Henoch-Schönlein purpura.

Henoch-Schönlein purpura is a small vessel vasculitis which is uncommon in adults. The presentations of adult-onset disease are different from those seen in childhood. The commonly-recognised serious gastrointestinal complications of childhood are less well-documented in adults. We report three cases of adult-onset Henoch-Schönlein purpura with severe gastrointestinal involvement. All were men, aged 22, 35 and 42 years, respectively. Two of these patients had evidence of mesenteric ischaemia on computed tomography of the abdomen. All three patients were successfully treated with steroids.

Wegener's granulomatosis presenting as diabetes insipidus.

Pituitary gland involvement in Wegener's granulomatosis (WG) occurs most commonly in the form of central diabetes insipidus (CDI). However, CDI as a presenting manifestation of WG is very rare. We report two such cases; one of them had multi-organ involvement at presentation, while other developed it during follow-up. CDI was reversible following cytotoxic drug therapy in one of them.

Successful management of tubercular subretinal granulomas.

PURPOSE: To report the successful management of 12 eyes of 11 patients with tubercular subretinal granulomas. METHODS: Eleven consecutive patients with a presumed or confirmed diagnosis of tubercular subretinal granulomas were treated with four-drug anti-tuberculosis chemotherapy with concomitant oral corticosteroids. Two patients underwent pars plana vitrectomy. RESULTS: The study included seven males and four women with a median age of 30.5 years. Ten eyes responded well to medical management and a final visual acuity of 20/80 or better was achieved in eight of them. The eyes subjected to pars plana vitrectomy had a relatively worse outcome. CONCLUSIONS: Tubercular subretinal granulomas are amenable to medical management provided an early diagnosis is made and treatment is initiated promptly. Once the diagnosis of presumed or confirmed tuberculosis is established, surgical intervention should be avoided.

Prevention of opportunistic infections in HIV infection by pentoxiphylline.

BACKGROUND & OBJECTIVES: Levels of tumour necrosis factor (TNF) are increased in patients with HIV infection leading to increased apoptosis and reduced CD4 cell life. Pentoxiphylline is a TNF inhibitor with properties that might make it useful for the treatment of HIV infection. These include improved cell mediated immunity and inhibition of viral replication. We carried out this study to determine the therapeutic utility of pentoxiphylline in improving constitutional manifestations, preventing opportunistic infections and sustaining CD4 counts among asymptomatic HIV infected individuals (i.e., those with no opportunistic infection). METHODS: Individuals with HIV infection who were over 18 yr of age and free of opportunistic infections were recruited in the study and followed up 4 weekly. CD4 counts were measured using a flowcytometer using anti-human CD4 intervals. Pentoxiphylline was prescribed in a dose of 400 mg thrice daily. RESULTS: Thirty three (18 males) patients with HIV infection were studied. During their follow up (mean 12.5 +/- 5.6 months) one patient each developed cryptococcal meningitis and fibrocavitary tuberculosis. Weight increased from 51.3 +/- 7.4 kg at baseline to 55.3 +/- 7.4 kg (P<0.05). Malaise, fatigue and appetite improved in all those with these complaints, except the two with opportunistic infections. Mean CD4 counts were 184 +/- 36.4/microl at baseline and increased to 210 +/- 28.6/microl3 at four weeks (P<0.05). The patients had stable CD4 counts over the follow up period since then, i.e., within 25 per cent of the previous levels. INTERPRETATION & CONCLUSION: Pentoxiphylline therapy in HIV infected individuals, who were free of opportunistic infections, improved their body weight, minimized opportunistic infections, increased and sustained CD4 counts. Given the low cost of the drug it could be recommended for the use in individuals who are at a high risk of developing opportunistic infections.

Caspase 1 and caspase 8 in HIV infected patients with and without tuberculosis.

BACKGROUND: Caspase 8 is involved in apoptosis mediated by Fas and p55 tumor necrosis factor receptor ligation in HIV infection. Apoptosis is partially mediated by interleukin-1beta-converting enzyme (caspase-1). AIMS: We determined apoptosis, using caspase-1 and caspase-8, among patients with HIV infection, with and without tuberculosis (TB), those with TB alone and healthy individuals. SETTING AND DESIGN: Cross-sectional analysis of caspase-1 and caspase-8 among patients with HIV infection, with and without TB, those with TB alone and healthy individuals. MATERIALS AND METHODS: Nineteen HIV infected patients with TB (HIV+/TB+) and 20 with HIV infection without TB (HIV+/TB-) were studied. Fifteen individuals with TB alone were disease controls (HIV-/TB+) and 20 were healthy controls (HIV-/TB-). Caspases were measured by single-step ELISA using commercially available monoclonal antibodies. STATISTICAL ANALYSIS: Two-way ANOVA and Pearson's correlation coefficient. RESULTS: Mean CD4 counts of HIV+/TB+ were lower than HIV+/TB- (p<0.05). OD value of caspase 1 in HIV+/TB+ was 0.295+0.05, while that in HIV+/TB- it was 0.302+0.18. It was 0.293+0.07 in HIV-/TB+ and in HIV-/TB- the values were 0.287+0.06. OD value of caspase 8 in HIV+/TB+ was 0.307+ 0.07, lower than HIV+/TB- (0.927+0.25). It was 0.008+0.03 in HIV-/TB+ and in HIV-/TB-, 0.074+0.004. Values of caspase 8 in patients with HIV infection (with/without TB) were higher than those with TB alone or healthy individuals (p<0.01). Levels of caspase 8 in HIV+/TB- were higher than patients with HIV+/TB+ (p<0.01). CONCLUSION: Levels of caspase-1 are not different irrespective of presence or otherwise of TB and HIV infection. Fas-related apoptosis is higher in HIV infection. With concomitant TB, levels of caspase 8 were lower as compared with those without TB.

Reduced apoptosis by pentoxiphylline among patients with HIV infection.

BACKGROUND: Apoptosis is a significant cause of CD4(+) T cell death. Caspase 8 (FLICE) is involved in apoptosis mediated by Fas and p55 tumor necrosis factor (TNF) receptor ligation. It is also partially mediated by interleukin-1beta (IL-1beta)-converting enzyme (ICE; caspase 1). We and others have shown that pentoxiphylline inhibits TNF-alpha. We used it among patients with HIV infection to determine if 24 weeks of therapy altered the levels of caspase 1 and caspase 8. PATIENTS AND METHODS: Nineteen HIV-infected patients having no opportunistic infection at the time of recruitment were administered pentoxiphylline 400 mg thrice daily for 24 weeks. Caspase levels were measured using a single-step ELISA using commercially available monoclonal antibodies against caspase 1 and caspase 8. RESULTS: Mean CD4 counts of the patients were 202.6+/-111.6 (/mm(3)). Mean OD value of caspase 1 among patients before therapy was 0.302+/-0.197 and was higher than that of controls (0.287+/-0.064), but this was not statistically significant. Following 24 weeks of therapy with pentoxiphylline, the OD value declined significantly to 0.164+/-0.028 among patients (p<0.001). Mean OD value of caspase 8 among patients prior to therapy was 0.927+/-0.249. This was significantly higher than that of controls, whose level was 0.0074+/-0.004 (p<0.001). Following 24 weeks of therapy with pentoxiphylline, the OD value declined to 0.199+/-0.064 among patients and this was significantly lower than the value at the start of treatment (p<0.001). CONCLUSION: Therapy with pentoxiphylline for 24 weeks is associated with a decline in the levels of caspase 1 and caspase 8. Since the drug is known to produce TNF inhibition, this might result in reduced apoptosis and an improved CD4 lymphocyte survival.

Human immunodeficiency virus infection in a patient with systemic lupus erythematosus.

We describe a 47 years lady with systemic lupus erythematosus (SLE) who was infected with human immunodeficiency virus (HIV), due to transfusion either by blood or platelet concentrate. There was a near remission in the disease and during the course of follow up she developed cryptococcal meningitis. The approach to the diagnosis of HIV infection in a patient with SLE, the effect of SLE on the virus and vice versa and some management issues in this setting are discussed.

Suppression of beta 2 microglobulin by pentoxiphylline therapy in asymptomatic HIV infected individuals.

Pentoxiphylline, an inhibitor of tumor necrosis factor-alpha (TNF-alpha) has been used in the treatment of human immunodeficiency virus (HIV) infection. The inhibition of TNF-alpha results in decreased immune activation. Beta 2 microglobulin (beta 2 M) has been used as a surrogate marker to study the progression of HIV infection. The objective of this study was to see if use of pentoxiphylline resulted in any decline in beta 2 M levels. Twenty patients with HIV infection who were free of opportunistic infections at the time of inclusion in the study and 18 age and sex matched controls were studied. beta 2 M was measured using an enzyme immunoassay before and four weeks after the start of treatment with pentoxiphylline. Mean levels of beta 2 M before therapy were 1.51 +/- 0.77 mg/l (range 0.78-3.8 mg/l) and were significantly higher (P < 0.001) than the levels among controls [0.72 +/- 0.06 mg/l (range 0.46-0.88 mg/l)]. beta 2 M levels in patients declined to 0.85 +/- 0.22 mg/l (range 0.72-1.0 mg/l) after four weeks of therapy and this was statistically significant (P < 0.001). Use of pentoxiphylline for four weeks results in a significant decline in the levels of beta 2 M suggesting that the level of immune activation is reduced with the therapy.

Vogt-Koyanagi-Harada syndrome following injury-induced progressive vitiligo.

We report a case of Vogt-Koyanagi-Harada (VKH), Syndrome wherein the patient developed ocular symptoms following injury-induced progressive vitiligo with immunologic evidence from the skin biopsy specimen of the vitiligo. This case supports the hypothesis that the cell-mediated immune process against a common melanocyte antigen plays an important role in the development and progression of the disease.

Pentoxiphylline reduces nitric oxide production among patients with HIV infection.

Tumour necrosis factor-alpha (TNF-alpha) and nitric oxide (NO) levels are elevated among patients with human immunodeficiency virus (HIV) infection. TNF-alpha is known to lower NO production. In this study we used a TNF-alpha inhibitor, pentoxiphylline, to treat patients with HIV infection who were free of opportunistic infections and see if NO production was altered with this drug. NO production was determined by spectrophotometric analysis using nitrite and citrulline as surrogate markers and TNF-alpha levels were determined by ELISA before and after 4 weeks of the treatment. Nineteen patients (ten males, mean age 36.6+/-5.2 years) and 16 age and sex matched healthy controls were studied. Mean CD4 counts of patients were 206.5 mm(3). Nitrite level among patients at recruitment was 99.7+/-26.5 nmol/ml (range 50-167 nmol/ml) and was significantly higher than 46.4+/-16.2 nmol/ml; the value of healthy controls (P<0.05). Patient levels declined significantly to 44. 2+/-19.7 nmol/ml (range 10-106.6 nmol/ml) following 4 weeks of therapy (P<0.01). Citrulline level at recruitment was 810.8+/-425.8 nmol/ml (range 366.6-1888.7 nmol/ml), which was significantly higher than 488.6+/-224.5 nmol/ml, the level of controls (P<0.01). There was a statistically significant decrease in these levels among patients to 533.6+/-299.5 nmol/ml (range 250-163.4 nmol/ml) after 4 weeks of therapy (P<0.01). TNF-alpha levels showed a significant decline in the OD values from 0.34+/-0.22 at the start of therapy to 0.24+/-0.18 (P<0.05). We conclude that the use of pentoxiphylline is associated with decrease in TNF-alpha levels and NO production.

Budd-Chiari syndrome: our experience of 71 patients.

BACKGROUND: Hepatic venous outflow obstruction (Budd-Chiari syndrome) is frequently encountered as a cause of portal hypertension at our centre. METHODS AND RESULTS: We studied the clinical presentation, therapeutic modalities and outcome of 71 patients with hepatic venous outflow obstruction between 1992 and 1997. Twenty-seven patients presented with acute disease, while 44 had chronic presentation. Abdominal pain, distension, jaundice and upper gastrointestinal bleeding were the commonest presenting symptoms. The majority of patients had distended veins, hepatomegaly, splenomegaly, ascites and ankle oedema. The diagnosis was made on the basis of inferior vena cavography/functional hepatography and pulsed Doppler ultrasonography and/or liver biopsy in 39 patients and pulsed Doppler ultrasonography and/or liver biopsy in 32 patients. Pulsed Doppler ultrasonography accurately detected the site of the block in 31 of 39 patients (79.4%). The obstruction was in the hepatic vein in 20 patients, in the inferior vena cava in 10, and in both in 41 patients. Aetiologically, four had pregnancy-related disease, four tumour-related, three hypercoagulable states, 18 inferior vena cava membranes and 42 were idiopathic. Of 30 patients in whom liver biopsy was carried out, eight had centrizonal congestion and necrosis, 13 had mixed features and nine had established cirrhosis. Seven patients underwent a shunt operation and surgical membranotomy was carried out in one. Three patients (4.2%) died in the hospital. CONCLUSIONS: Hepatic venous outflow obstruction is a common problem; patients present with abdominal pain, distension, jaundice, distended veins, ascites and ankle oedema. Chronic presentation is more frequent. Pulsed Doppler ultrasound, venography and liver biopsy are very helpful in diagnosis.

Non-fatal ethylene dibromide ingestion.

Ethylene dibromide (1,2-dibromoethane) is widely used to fumigate grain and fruit in India. However, acute poisoning due to it has rarely been reported in the literature and most of these patients had an fatal outcome. We describe the suicide attempt of a young male who ingested an ampoule (3 ml) of it, developed acute hepatic and renal failure, metabolic acidosis and coagulopathy but survived following supportive measures.

Acute renal failure due to nontraumatic rhabdomyolysis following binge drinking.

Nontraumatic rhabdomyolysis is an important but under-recognized cause of acute renal failure. In alcoholics, rhabdomyolysis most frequently develop following muscle necrosis during alcohol-induced coma, but has also been described rarely in those without prolonged coma or seizures. We describe a patient who developed myoglobinuric acute renal failure requiring dialysis following binge drinking in the absence of convulsions or coma. The renal biopsy showed acute tubular necrosis with pigment casts.

Epstein-Barr virus induced non-Hodgkin's lymphoma as a presenting manifestation of acquired immune deficiency syndrome.

A 30 year old, human immunodeficiency virus (HIV) positive patient presented with fever and intra-abdominal lymphadenopathy. Cytology smears from the nodes showed a high grade Non-Hodgkin's lymphoma (NHL) which was B cell in origin. NHL was the acquired immune deficiency syndrome (AIDS) defining disease in this patient. Polymerase chain reaction (PCR) studies on tumour tissue showed presence of Epstein Barr Virus.

Diagnostic efficacy of polymerase chain reaction in granulomatous uveitis.

SETTING: The granulomatous uveitis, multifocal choroiditis and periphlebitis have been suspected to be of tubercular origin but no definitive reports about detection of etiological agents have been documented in the literature. Conventional bacteriological methods are not generally helpful in diagnosing ocular tuberculosis due to difficulty with potential morbidity associated with obtaining the biopsy material from the eye. Thus, the diagnosis of ocular tuberculosis is most often presumptive. OBJECTIVE: We evaluated the role of polymerase chain reaction (PCR) for detection of Mycobacterium tuberculosis in the aqueous humor samples obtained from eyes with active uveitis. METHODS: Aqueous samples from 53 patients having cellular reaction in the anterior chamber along with any one or more of the following: 1) active vasculitis; 2) anterior vitreous cells; 3) snowball opacities; 4) snow banking in the pars plana; 5) retinochoroiditis were withdrawn by anterior chamber paracentesis and subjected to PCR. Seventeen samples from patients with definite clinical diagnoses other than tuberculosis formed a disease control group. Fifteen aqueous samples obtained from healthy subjects undergoing routine cataract surgery served as healthy controls. PCR was performed using primers capable of amplifying a 150 b.p. segment from a conserved repetitive sequence in the genome of M. tuberculosis. RESULTS: Twenty out of the 53 samples (37.7%) in the study group were positive where as only one sample out of 17 in the disease control group (5.7%) showed a weakly positive band. No sample from the healthy control group showed a positive PCR. CONCLUSION: Our study shows that PCR can be effectively used for the diagnosis of intraocular tuberculosis in the presence of uveitis.

Cataract surgery in patients with dry eyes.

PURPOSE: To evaluate the potential causes of postoperative complications and the visual outcome after surgery for age-related cataract in dry eyes. SETTING: Tertiary-care multidisciplinary referral medical institution. METHODS: The records of 15 patients (21 eyes) with age-related cataract, a Schirmer value of 5.0 mm or less in 5 minutes, and a tear-film breakup time of 5 seconds or less having complications after cataract surgery were reviewed. Patients were assigned to 1 of 2 groups: dry eye with probable secondary Sjögren's syndrome (Group 1); dry eye without connective tissue disorders (Group 2). The surgical procedure, preoperative and postoperative medications, postoperative complications, and final visual outcome were analyzed. RESULTS: Ten eyes (8 patients) in Group 1 and 11 (7 patients) in Group 2 had cataract surgery. In Group 1, postoperative endophthalmitis developed in 3 eyes and peripheral keratolysis in 4; 5 eyes attained a visual acuity between 6/60 and 6/18 2 years after surgery. In Group 2, filamentary keratitis developed in 6 eyes and peripheral keratolysis in 2 eyes; 6 eyes achieved a visual acuity of 6/12 or better 2 year after surgery. A significant decrease in visual acuity occurred between 3 months and 2 years postoperatively in both Group 1 (P = .010) and Group 2 (P = .0005). CONCLUSION: Cataract surgery in dry eyes had fewer complications and better visual outcome in patients who did not have connective tissue disease than in those who did.

Pedunculated large leiomyoma of esophagus.

We report a patient with pedunculated esophageal leiomyoma which was 20 cm in length. Barium swallow had shown a grossly dilated esophagus with filling defect along its whole length, giving an appearance suggesting achalasia and retained food. The patient is doing well after transhiatal esophagectomy.

Pulmonary sarcoidosis: spirometric correlation with transbronchial biopsy.

We studied the relationship between the histopathology obtained by trans-bronchial lung biopsy (TBLB), and spirometric indices in 28 patients of pulmonary sarcoidosis in whom the diagnosis was confirmed. There was a rough correlation between FVC and the histologic granuloma load, interstitial inflammation and the overall histopathological score. Radiological features did not correlate with either spirometry or histopathology.

Lack of expression of c-myc oncogene in peripheral blood mononuclear cells of patients with active rheumatoid arthritis.

We looked for the expression of c-myc oncogene, one of the genes that enhance apoptosis, in 11 patients with active rheumatoid arthritis (RA) along with five patients with osteoarthritis (OA) knee as disease controls and six healthy volunteers. A dot-blot assay using a probe specific for c-myc oncogene was performed on total RNA obtained from peripheral blood mononuclear cells. There was no expression in patients with active RA and healthy volunteers. One patient with OA expressed c-myc. Lack of expression of c-myc suggests that in active RA circulating lymphocytes are not in the replicative phase despite ongoing disease activity.