Tumor necrosis factor-alpha levels in patients with HIV with wasting in South Asia.

Tumor necrosis factor (TNF)-alpha is thought to play an important role in wasting; but TNF-alpha levels have not been consistently found to be high in AIDS wasting. We conducted this study to determine any correlation between TNF-alpha levels and wasting in HIV-positive patients in a developing country. TNF-alpha levels were measured in four groups of patients: Group 1, HIV/AIDS with wasting (n = 25); group 2, HIV/AIDS without wasting (n = 47); group 3, HIV-negative patients with tuberculosis with wasting (n = 25); and group 4, healthy controls (n = 25). Wasting was defined as a body bass index (BMI)

Vitamin A nutritional status of rural community of Khol block in Haryana, North India. A collaborative study.

A nutritional and diet survey was carried out in 2,192 persons belonging to all age groups in a rural community. Vitamin A consumption was less than the recommended daily allowance in persons of all age groups. Bitot's spots and night blindness were detected in 7.1% and 7.2% of the population, respectively. Ocular signs of vitamin A deficiency were more frequently observed in age groups above 5 years as compared to the preschool children. There was no association of vitamin A deficiency with different grades of protein-calorie malnutrition in preschool children. Keratomalacia was extremely rare and was observed only in one child. The study suggests that the rural area studied was a high prevalence zone for vitamin A deficiency which did not have its serious consequences due to relatively adequate protein-calorie nutritional status of the population.

Wegener's granulomatosis with complete heart block.

We describe a patient with Wegener's granulomatosis (WG) who developed complete heart block. Prompt treatment with steroids and cyclophosphamide led to regression of the complete heart block. The patient was left with a persistent first degree atrio-ventricular block, however. Early treatment may obviate the need for permanent pacing in such cases.

Cardiac involvement in Dengue Haemorrhagic Fever.

We studied 17 consecutive patients of Dengue Haemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS) to assess cardiac function by radionuclide ventriculography, echocardiography and electrocardiography (ECG) during the epidemic of Dengue virus type-2 (DEN-2) in Delhi, India (1996). Case definitions laid down by the WHO were followed. Fourteen patients were seropositive for Dengue infection. In radionuclide ventriculography study, the mean left-ventricular ejection fraction was 41.69 (5.04% (range 33-49%) and 7 patients had an ejection fraction less than 40%, global hypokinesia was detected in 12 (70.59%) patients. In echocardiography, the mean ejection fraction was 47.06 (3.8%). Eight patients had Dengue Shock Syndrome and the mean ejection fraction was 39.63% (4.97% in radionuclide ventriculography, out of which 5 patients had an ejection fraction below 40%. To find out the nature of myocardial involvement, 99m Tc-pyrophosphate imaging was done in 4 patients and it was discontinued further because no myocardial necrosis was detected in those patients. Five patients had ST and T changes in the electrocardiogram, radionuclide ventriculography and echocardiography revealed no abnormalities after 3 weeks of follow up and the ejection fraction was more than 50% in all cases. Global hypokinesia also improved and ECG changes reverted back to normal within 3 weeks. Acute reversible cardiac insult may be noticed in Dengue Haemorrhagic Fever/Dengue Shock Syndrome and could be responsible for hypotension/shock seen in some of these patients. Further studies are required to establish the pathogenic mechanisms of cardiac dysfunction in patients with Dengue Haemorrhagic Fever/Dengue Shock Syndrome.

In vivo proton magnetic resonance spectroscopy (MRS) and single photon emission computerized tomography (SPECT) in systemic lupus erythematosus (SLE).

Neuropsychiatric involvement in SLE (NP-SLE) may not be picked up by routine neuroimaging procedures like computerized tomography (CT) or magnetic resonance imaging (MRI). We prospectively studied the role of single photon emission computerized tomography (SPECT) and magnetic resonance spectroscopy (MRS) in detection of NP-SLE in 20 patients with lupus (10 with clinical NP involvement and 10 without) and 9 healthy controls. MRI abnormalities were seen in 5/10 patients with NP-SLE while the MRI was normal in all the lupus patients without clinical NP involvement. Perfusion defects on SPECT were seen in as many as 8/10 patients with NP-SLE while only 1/10 lupus patients without clinical NP involvement and none of the healthy controls demonstrated perfusion defects. MRS revealed abnormal metabolite ratios in all patients with NP-SLE and as many as 8 lupus patients without clinical NP features. Normal metabolite ratios were observed in healthy controls. SPECT and MRS can help detect changes not evident on MRI and may serve as useful supplements to existing neuroimaging techniques in the diagnosis of NP-SLE. The precise significance of alterations in regional cerebral blood flow on SPECT and neurometabolite ratios on MRS needs larger, longitudinal studies.

A prospective study of Lyme arthritis in north India.

Twenty seven patients presenting with mono/oligoarticular disease of unknown etiology were prospectively screened for Lyme arthritis. In addition, 12 healthy blood bank donors, 25 individuals with rheumatoid arthritis (disease controls), and 20 deer handlers and veterinarians were also screened for IgG antibodies to Borrelia burgdorferi. Only one patient tested borderline positive for antibodies to B. burgdorferi (more likely false positive). None of the healthy subjects, disease controls or occupationally exposed individuals exhibited serological evidence of exposure to B. burgdorferi. Screening for Lyme disease may not be warranted while investigating mono/oligoarthritides of unknown etiology in this part of the country.

Estimation & significance of serum & synovial fluid malondialdehyde levels in rheumatoid arthritis.

Serum and synovial fluid (SF) levels of malondialdehyde (MDA), a marker of free radical induced lipid peroxidation, were estimated in patients of rheumatoid arthritis (RA) and compared with healthy controls and patients of osteoarthritis (OA). While serum MDA levels were similar in healthy controls (0.24 +/- 0.10 nmol/ml) and OA (0.28 +/- 0.11 nmol/ml), the serum levels in RA (0.47 +/- 0.19 nmol/ml) were significantly higher as compared to both healthy controls and OA patients; and correlated with synovial fluid (SF) MDA levels. No difference was observed in SF-MDA levels in RA (0.17 +/- 0.07 nmol/ml) and OA (0.16 +/- 0.09). MDA levels did not correlate with markers of disease activity in RA like joint counts, duration of morning stiffness, erythrocyte sedimentation rate etc. Increased serum MDA levels in RA suggest the role of free radicals in the pathogenesis of this inflammatory arthropathy and support the need for further studies assessing the therapeutic role of free radical scavengers in RA.

A study of autoimmune markers in hepatitis C infection.

BACKGROUND & OBJECTIVES: Hepatitis C virus (HCV) infection is associated with several autoimmune markers. Despite HCV being common in India, no information on this aspect is available. This study was undertaken to ascertain the frequency and clinical significance of autoimmune markers like rheumatoid factor (RF), antinuclear antibodies (ANA), antibodies to double stranded deoxyribonucleic acid (dsDNA), anti neutrophil cytoplasmic antibody (ANCA), anti smooth muscle antibodies (ASMA), anti liver kidney microsomal 1 antibodies (anti LKM1), anti gastric parietal cell antibodies (anti GPCA), anti mitochondrial antibodies (AMA), anti cardiolipin antibodies (ACL) and cryoglobulins in HCV infection and to determine the effect of treatment on these markers. METHODS: Twenty five patients with chronic hepatitis C and 25 healthy controls were studied. Cryoglobulins were detected by cryoprecipitation, RF by latex agglutination, anti dsDNA and ACL by ELISA while indirect immunofluorescence was used to detect all other autoantibodies. RESULTS: Eighteen patients (72%) demonstrated autoimmune markers. RF, cryoglobulins and anti LKM1 antibodies were the most frequently detected markers (in 32% patients each). ASMA, perinuclear ANCA (pANCA), ANA and anti GPCA were seen in 24, 20, 12 and 4 per cent patients respectively. None of the patients exhibited ACL, AMA or antibodies to dsDNA. No antibodies were detected in healthy controls. Sixty per cent of the patients had rheumatological symptoms. Of the seven patients followed up after treatment with alpha interferon, only two exhibited persistence of RF, while symptoms and other markers disappeared. INTERPRETATION & CONCLUSION: Rheumatological symptoms and autoimmune markers are common in HCV infection and are usually overlooked. Patients with unexplained joint pains and/or palpable purpura should be screened for HCV. Further studies are needed to delineate fully the link between infection and autoimmunity.

Cardiac involvement in limited systemic sclerosis: non-invasive assessment in asymptomatic patients.

Nineteen patients with limited systemic sclerosis (SSc) and without any cardiac symptoms were evaluated non-invasively for silent cardiac involvement using electrocardiography; M-mode, two-dimensional and Doppler echocardiography, and resting and post exercise radionuclide ventriculography. Left anterior hemiblock and mild pericardial effusion were seen in two patients. The interventricular septal thickness and left ventricular posterior wall thickness were greater in patients compared with controls. Patients with limited SSc also exhibited low early diastolic filling velocities and a low early diastolic atrial filling ratio. However, these values did not correlate with the age of the patient or disease duration. Eight patients (42.1%) were found to have cardiac dysfunction, of which four had combined systolic and diastolic dysfunction. Isolated systolic and diastolic dysfunction was seen in three patients and one patient, respectively. The age and disease duration in patients with cardiac dysfunction did not differ from patients without cardiac dysfunction. Functional cardiac involvement occurs in a large proportion (42.1%) of patients with limited SSc, and can be easily picked up by non-invasive methods such as echocardiography and radionuclide ventriculography. The prognostic significance of these findings requires further long term studies.

Utility of an observation unit in the emergency department of a tertiary care hospital in India.

This retrospective study was conducted to evaluate whether an observation unit (OU) attached to the emergency department (ED) of a tertiary care hospital in India is safe, is effective in minimizing hospitalization of acutely ill patients and is acceptable to the patients. Of 115,916 patients who attended the ED, 11,130 (9.6%) were observed in the OU. The average period of observation was 7.74 h. Of the patients observed, 21.3% required hospitalization, while 78.5% were discharged after treatment. Twenty-four patients left the hospital against medical advice, and three patients died in the OU. It is concluded that an OU in the ED is safe in treating acutely ill patients, is effective in reducing substantially the number of patients requiring admission to the hospital, and is acceptable to the patients.

Enalapril-induced cough in the emergency department.

A case of enalapril-induced cough is reported. In the Emergency Department, the patient initially was misdiagnosed with bronchial asthma and, later, with early congestive heart failure, despite normal physical examination and investigations. The cough subsided within 5 days of cessation of enalapril. It is important to recognize this side effect in patients taking enalapril.

Brain death and organ donation.

Brain death is the irreversible cessation of all brain functions. Brainstem death is the 'physiological core' of brain death. The Indian Parliament has given legal recognition to brain death though it applies only in the context of performance of organ transplantation. Brain death is diagnosed if there is irreversible loss of consciousness, absence of brainstem reflexes and apnoea. Care and diligence in the application of the criteria for brain death provide important safeguards for Individual patients and the community in general. These criteria also allow death to be diagnosed with certainty prior to the occurrence of circulatory arrest. Solid organ transplantation has become possible through the diagnosis of brain death but is not the primary consideration; the management of a potential organ donor, who is brain dead, is also vital. If optimal preservation of organs for transplantation is to be achieved the clinician needs to understand the pathophysiology and consequences of changes occurring in various organs after brain death and active management is required to reverse or control these changes. Discussions about organ donation with relatives of brain deed patients are never easy. These should always be frank and sympathetic. It has been suggested that those whose interests lie in transplantation must bear the responsibility of educating the general public. This will help intensivists who expose themselves knowingly to the unpleasant aspects of organ donation.

Liver in kala-azar.

Sixty patients with kala-azar were studied for liver involvement. Clinically none had any evidence of chronic liver disease. Biochemical evidence of hepatitis was seen in about 25% of cases while radiological and radionuclide studies failed to reveal portal hypertension and/or cirrhosis of liver in any of the patients. Histopathology of the liver in 18 patients failed to reveal any evidence of chronic liver disease or cirrhosis. It is suggested that portal hypertension and cirrhosis of liver probably do not occur as a consequence of kala-azar.

A study of Helicobacter pylori in north Indian subjects with non-ulcer dyspepsia.

A prospective case control study was conducted in 50 patients with non-ulcer dyspepsia (NUD) and 10 age and sex matched controls to determine the prevalence of Helicobacter pylori in patients with NUD and to correlate symptoms, histology and presence of H pylori in gastric biopsies. Endoscopic biopsies from antrum and fundus were subjected to urease test and histological examination. On histology, H pylori was identified in 27 (54%) NUD patients and in one of 10 controls. Urease test was positive in 31 (62%) antral and 21 (42%) fundal biopsies in patients with NUD and in only one (10%) of 10 antral biopsies in the control group. On histology, gastritis was present in the antrum in 46 (92%) NUD patients and in the fundus in 40 (80%) cases; of these, 27 (54%) and 15 (30%) had H pylori in antral and fundal biopsies respectively. The severity of antral gastritis correlated with the density of H pylori (p < 0.05).

Ultrasonographic assessment of gall bladder kinetics in the elderly.

BACKGROUND: The incidence of gallstones increases with age but the factors that influence gallstone formation in the elderly are poorly understood. Proposed factors include changes in bile composition and hypomotility of the gall bladder. Studies on gall bladder motility in the elderly have provided conflicting results, and none has been reported from India. AIM: To determine gall bladder contractility in healthy elderly subjects and compare it with that in young healthy volunteers. METHODS: Thirty healthy elderly (above the age of 60 years) and 30 young volunteers with no abdominal complaints were studied. Using real-time ultrasonography and the ellipsoid method, gall bladder volume was measured after overnight fast and at 10, 20, 30, 40, 50 and 60 minutes after a standard fatty meal. Residual volume, delta volume and ejection fraction were calculated. RESULTS: Mean fasting gall bladder volume in elderly subjects was higher than that in young subjects (13.5 [5.8] mL vs 10.9 [3.6] mL; p < 0.05). However, there was no difference in the 60-min postprandial residual gall bladder volumes in the two groups. Change in gall bladder volume and ejection fraction were also similar in the two groups. CONCLUSION: There was no difference in gall bladder emptying between elderly and young subjects though the fasting gall bladder volume was higher in the elderly.

Pericardial mesothelioma presenting as a mediastinal mass.

A case of malignant mesothelioma of the pericardium, who presented with an anterior mediastinal mass, is reported. Such a presentation of the pericardial mesothelioma is distinctly rare. As in most of the other reported cases, our patient also did not have any exposure to asbestos. The diagnosis in the present case was established after surgery. Most of the cases reported in the literature, were diagnosed only at postmortem. The treatment of choice is surgical resection of the tumour. The prognosis of pericardial mesothelioma is poor and till now, only two long survivals have been reported.

Circulating immune complexes in tuberculosis.

To examine whether any correlation exists between the levels of circulating immune complexes (CICs) and the activity of tuberculosis, CICs were measured in the sera of 75 patients with active tuberculosis and in 25 control subjects using polyethylene glycol method. The effect of drug treatment on the levels of CICs was also estimated in 25 patients. It was found that levels of CICs were elevated in most of the untreated patients (96%) of tuberculosis and the CICs levels fell to control values in 64% of patients at the end of treatment.

Acute leukemia presenting as pericardial effusion--a case report.

We report a patient with acute lymphoblastic leukemia, who presented with pericardial effusion. There was no haematologic evidence of leukemia at the time of presentation. The pericardial effusion resolved with chemotherapy. Although a common finding at autopsy, clinically evident pericardial effusion is rare in leukemia. It is also extremely rare for pericardial effusion to be the presenting feature or to antedate haematologic evidence of leukemia. Physician awareness is important to make a correct diagnosis.

Legionella as a lower respiratory pathogen in north India.

One hundred patients of lower respiratory tract infection (LRTI) were prospectively studied over 2 years to find out if Legionella is a causative agent in these patients. In addition, 50 environmental samples and 50 age and sex matched controls were studied. Culture and direct fluorescent antibody testing (DFA) of respiratory tract secretions, and serodiagnosis by indirect immunofluorescence (IIF) and ELISA, were employed to detect Legionella. Respiratory tract secretions from all patients were negative for Legionella on culture and DFA. Low antibody titters to Legionella were observed in 21 patients and these could be attributed to cross reaction with other gram-negative bacteria. All environmental samples and controls tested negative for Legionella. Legionella does not seem to be an important lower respiratory tract pathogen in this part of the country and empirical addition of erythromycin to treatment regimens for pneumonia is not warranted in our setting.

Dengue virus infection during post-epidemic period in Delhi, India.

Dengue fever (DF) and dengue hemorrhagic fever (DHF) are major public health problems in India. During the period following an epidemic, a study was carried out using virological and serological tests for confirmation of suspected cases of dengue virus infection in fever cases presenting to the All India Institute of Medical Sciences. Serum samples of suspected DF/DHF cases were processed from January to December 1997. In 37 samples from patients with fever of less than 5-day duration, received on ice, virus isolation was attempted in C6/36 clone of Aedes albopictus cell line, followed by indirect fluorescent antibody staining with monoclonal antibodies to dengue viruses 1 to 4. One hundred and forty-three serum samples from patients with more than 5 days fever were tested for dengue specific IgM antibody by either MAC-ELISA or a rapid immunochromatographic assay. Dengue virus type 1 was demonstrated by culture in 8 (21.6%) of 37 serum samples and IgM antibody could be detected in 42 (29.4%) of the 143 serum samples by the serological methods. The peak of dengue virus infection was seen from September to November 1997.