Disseminated Tuberculosis Masquerading as a Uterine Cervical Mass in an Immunocompetent Young Female: A Case Report.

Concurrent tubercular involvement of two or more non-contiguous organs is termed disseminated tuberculosis (TB) and is rare in immunocompetent patients. We describe the case of a young immunocompetent woman with disseminated TB who presented with primary complaints of amenorrhea and dysuria. Abdominal ultrasound showed a uterine cervical mass, which on histopathological evaluation revealed epithelioid granulomata with Langhans giant cells and acid-fast bacilli (AFB). Her chest radiograph showed scattered air space opacities bilaterally, and contrast-enhanced computed tomography of the abdomen revealed the involvement of bilateral kidneys, para-aortic lymph nodes, adrenals, sacroiliac regions, and the gastrointestinal tract. A colonoscopy picked up an ulcer in the terminal ileum, which on histopathology was positive for AFB. The patient was started on anti-tubercular treatment.

Infection of the ovarian cyst: a rare presentation of extraintestinal salmonellosis.

A woman in her early 20's presented with fever and unintentional weight loss of 4 kg over a period of 1 month and abdominal pain for 10 days. Empirical antibiotic therapy administered prior to hospitalisation was not successful. Evaluation for fever was unrewarding except for an abnormal ultrasound which showed two cysts with the largest dimension of 9 cm in the right adnexal region. All blood cultures were sterile. She underwent laparoscopic cystectomy. Bacterial culture of cyst fluid grew Salmonella enterica subspecies enterica serotype Typhi which was found to be resistant to fluoroquinolones. The case emphasises the fact that localised infection of the ovarian cyst can occur in extraintestinal salmonellosis that can have a negative blood culture and can mimic ovarian malignancy.

Unveiling the Neurotoxicity of Metronidazole: A Clinical Conundrum.

Metronidazole, a commonly used antiprotozoal agent, has been linked to neurotoxicity in a few individuals. We present the case of a 61-year-old gentleman diagnosed with a liver abscess, who received a total dose of 64 g of metronidazole over a four-week duration. He subsequently developed slurred speech, numbness, and tingling sensation in both feet. His neuroimaging revealed T2 hyperintensities in the bilateral dentate nuclei and withdrawal of the drug led to symptomatic improvement in the patient. Metronidazole is known to produce neurological manifestations with involvement of peripheral nerves and cerebellum commonly. In the present case, the cumulative dose impact of metronidazole on the dentate nucleus was evident.

Candidate Gene Expression in Regional Population and Its Relevance for Radiation Triage.

Quantification of gene expression signatures has been substantiated as a potential and rapid marker for radiation triage and biodosimetry during nuclear emergencies. Similar to the established biodosimetry assays, the gene expression assay has drawbacks such as being highly dynamic and transient, not specific to ionizing radiation, and also influenced by confounding factors such as gender, health status, lifestyle, and inflammation. In view of that, prior knowledge of baseline expression of certain candidate genes in a population could complement the discrimination of the unexposed from the exposed individuals without the need for individual pre-exposure controls. We intended to establish a baseline expression of reported radiation-responsive genes such as CDKN1A, DDB2, FDXR, and PCNA in the blood samples of healthy human participants and then compare it with diabetic/hypertension participants (as a chronic inflammatory condition) drawn from south Indian population. Further, we have examined the appropriateness of the assay for radiation triage-like situations; i.e., the expression profiles of those genes were examined in the participants who underwent X-ray-based medical imaging. Acute inflammation induced by lipopolysaccharide exposure in the blood significantly increased the fold expression of those genes (p < 0.0001) compared to the control. Whereas the basal expression level of those genes among the participants with the inflammatory condition is marginally higher than those observed in the healthy participants; despite the excess, the fold increase in those genes between the groups did not differ significantly. Consistent with the inflammatory participants, the basal expression level of those genes in the blood sample of participants who received X-radiation during neuro-interventional and computed tomography imaging is marginally higher than those observed in the pre-exposure of respective groups. Nevertheless, the fold increase in those genes did not differ significantly as the fold change fell within the two folds. Thus, overall results suggest that the utility of CDKN1A, DDB2, FDXR, and PCNA gene expression for radiation triage specific after very low-dose radiation exposure needs to be interpreted with caution for a much more reliable triage.

Estimation of Upper Limit of Normal for Serum Alanine Transaminase in Healthy South Indian Population.

Alanine aminotransferase (ALT) is the most common and cost effective screening test for asymptomatic liver disease. There is paucity of data on normal ALT among healthy individuals in India. An observational cross sectional study was conducted from January to July 2013 to estimate the upper limit of normal for ALT in healthy south Indian population. Adults undergoing voluntary or pre-employment health screening were included. Those with current and past alcoholism or smoking, acute illness or hospitalization during preceding 12 months, non-steroidal anti-inflammatory or over the counter medication use within a month, current or past intake of herbal medications, any chronic medical illness, abnormal body mass index (BMI), fatty liver in ultrasound, abnormality in haemoglobin, platelet count, blood sugar, creatinine, lipid profile and thyroid function test and positive serology (Hepatitis B, C or HIV) were excluded. A total of 2600 subjects were screened. 344 were included for analysis. Mean age was 35 years in men and 34.83 years in women, with a mean BMI of 22.2 kg/m2 in men and 21.8 kg/m2 in women. The mean ALT in men and women were 21.87 ± 2.9 (97.5th percentile 28 U/L) and 19.35 ± 3.3 (97.5th percentile 24 U/L) respectively. In conclusion, mean and upper limit of ALT (97.5th percentile) in south Indian men was 21.87 and 28 IU/L and women were 19.35 and 24 IU/L respectively. There is a need to re-consider ALT levels in our population for better detection of individuals at risk for liver disease.

Low dose short duration pulsed electromagnetic field effects on cultured human chondrocytes: An experimental study.

BACKGROUND: Pulsed electromagnetic field (PEMF) is used to treat bone and joint disorders for over 30 years. Recent studies demonstrate a significant effect of PEMF on bone and cartilage proliferation, differentiation, synthesis of extracellular matrix (ECM) and production of growth factors. The aim of this study is to assess if PEMF of low frequency, ultralow field strength and short time exposure have beneficial effects on in-vitro cultured human chondrocytes. MATERIALS AND METHODS: Primary human chondrocytes cultures were established using articular cartilage obtained from knee joint during joint replacement surgery. Post characterization, the cells were exposed to PEMF at frequencies ranging from 0.1 to 10 Hz and field intensities ranging from 0.65 to 1.95 µT for 60 min/day for 3 consecutive days to analyze the viability, ECM component synthesis, proliferation and morphology related changes post exposure. Association between exposure doses and cellular effects were analyzed with paired't' test. RESULTS: In-vitro PEMF exposure of 0.1 Hz frequency, 1.95 µT and duration of 60 min/day for 3 consecutive days produced the most favorable response on chondrocytes viability (P < 0.001), ECM component production (P < 0.001) and multiplication. Exposure of identical chondrocyte cultures to PEMFs of 0.65 µT field intensity at 1 Hz frequency resulted in less significant response. Exposure to 1.3 µT PEMFs at 10 Hz frequency does not show any significant effects in different analytical parameters. CONCLUSIONS: Short duration PEMF exposure may represent a new therapy for patients with Osteoarthritis (OA).

Spontaneous splenic rupture in dengue fever with non-fatal outcome in an adult.

A 26-year-old male presented with fever for five days and abdominal pain for 24 hours. System examination identified a soft abdomen with diffuse tenderness. CT-abdomen findings were consistent with splenic rupture with intra and peri-splenic hematoma. Laboratory investigations showed a platelet count of 40,000 per mm(3). In due course he developed hypotension and underwent splenectomy. Non-structural protein 1 (NS1) dengue antigen was positive in the admission sample and IgM dengue antibodies were detected in the follow-up sample. Histopathology of the spleen showed normal architecture with no evidence of hyperplasia, cellular infiltrates or haematological malignancy. Splenic rupture is a rare, but potentially fatal complication of dengue fever and severe dengue which should be suspected when a patient presents with abdominal pain and hypotension. Our case highlights the occurrence of splenic rupture in the viremic phase of dengue illness before the development of IgM antibodies. 

Hypertensive retinal changes, a screening tool to predict microalbuminuria in hypertensive patients: a cross-sectional study.

BACKGROUND: Studies have shown that hypertensive retinal changes (HRC) have a moderate accuracy in predicting microalbuminuria (MA) in elderly hypertensive patients (age >65 years). This study is an effort to identify a similar relationship in hypertensive patients aged <65 years. METHODS: Eight hundred and seventy consecutive hypertensive patients (males, 460; females, 410) aged 18-65 years were assessed for their demographic characteristics and other laboratory variables. Patients with diabetes mellitus, metabolic syndrome and overt nephropathy were excluded. Optic fundi were assessed for HRC after pupillary dilatation, which were photographed. MA (albumin-creatinine ratio) was measured as an average of two non-consecutive overnight spot urine samples. RESULTS: Mean age was 45 +/- 13.4 years. Prevalence of MA and HRC was 36.7 and 38%, respectively. MA showed a strong association with HRC (P < 0.0001). Logistic regression identified the association between MA, duration of hypertension (HTN) (P = 0.016), smoking (P = 0.012) and elevated high-sensitivity C-reactive protein (HsCRP) (P = 0.032). HRC were associated with duration of HTN (P = 0.021) and smoking (P < 0.0001). Tests of accuracy for HRC as a predictor of MA showed sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio of a positive test and likelihood ratio of a negative test of 78%, 86%, 76%, 87%, 5.2 and 0.26, respectively. Area under the receiver operating characteristic curve was 81%. Similarly, the individual grades of HRC had a moderate predictive accuracy. Higher grades had higher predictive accuracy. Inter- and intra-observer correlation in interpreting HRC was acceptable. CONCLUSIONS: HRC of any grade have moderate accuracy in predicting MA and hence can be used as a cost-effective screening tool to predict MA especially in a resource-poor setting.

Paraneoplastic (non-metastatic) adrenal insufficiency preceded the onset of primary lung cancer by 12 weeks.

Clinically evident adrenal insufficiency associated with lung cancer is a rare entity. Among reported cases, adrenal insufficiency has occurred with or succeeded the primary lung cancer. Adrenal insufficiency has also been secondary to metastasis to the adrenal gland. The present report concerns a 61-year-old man, a chronic smoker, who presented to us with symptomatic adrenal insufficiency. He had no evidence of lung cancer during this visit. The primary lung cancer was only identified 12 weeks later. Additionally, his adrenals showed no evidence of metastasis. Hence his adrenal insufficiency had been a paraneoplastic manifestation of the lung cancer, and it had also preceded the primary by 12 weeks.

Accuracy of retinal changes in predicting microalbuminuria among elderly hypertensive patients: a cross-sectional study from a teaching hospital in South India.

OBJECTIVE: Microalbuminuria is an important marker of end organ damage in hypertensive patients, but is often not tested for, especially in a resource-poor setting. We studied the accuracy of retinal changes in predicting microalbuminuria among a cohort of geriatric hypertensive patients. METHODS: One hundred and eighty elderly hypertensive patients aged more than 65 years were assessed for their demographic characteristics, smoking status, duration of hypertension, current severity of hypertension, body mass index, left ventricular hypertrophy by electrocardiogram (ECG), and high sensitivity C-reactive protein (HsCRP). Optic fundi were assessed for retinopathy after pupillary dilatation, and were photographed. Microalbuminuria (albumin-creatinine ratio) was measured as an average of two nonconsecutive overnight spot urine samples. Patients with pre-diabetes, diabetes, metabolic syndrome, treatment with angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, overt nephropathy or proteinuria, and active infection were excluded. RESULTS: Mean age was 74 +/- 6.56 years. One-third were obese and 18.9% had left ventricular hypertrophy. Prevalence of microalbuminuria was 39.4% and prevalence of retinopathy was 40%. Microalbuminuria showed a strong association with retinopathy (P < 0.0001). Logistic regression identified association of microalbuminuria with duration of hypertension (P = 0.001) and elevated high sensitivity C-reactive protein (P = 0.021). Retinopathy was associated with duration of hypertension (P = 0.001) and smoking (P < 0.0001). Tests of accuracy for retinopathy as a predictor of microalbuminuria showed a sensitivity of 72% and specificity of 81%. CONCLUSION: Prevalence of microalbuminuria and retinopathy were quite high in our cohort of elderly hypertensive patients. Retinal changes of any grade probably have moderate accuracy in predicting microalbuminuria and hence we can initiate work-up for target organ damage, especially in a resource-poor setting.