Clinico-laboratory Profile and Outcomes of Megaloblastic Anemia presenting as Severe Pyrexial Illness mimicking Tropical Infection

Background: Anemia-causing fever has been described in patients with megaloblastic anemia. Although the exact mechanism of this is unknown, high-grade fever is relatively less reported. Materials and methods: This prospective observational study included all new cases of megaloblastic anemia presenting with febrile illness (>101°F) during a 3-year period. Patients with existing anemia, comorbidities, and other causes of macrocytosis were excluded. A detailed evaluation for megaloblastic anemia and workup for excluding tropical infections was done. The patients were treated with parenteral vitamin B12, folic acid, and other hematinics. Results: Around 24 cases of megaloblastic anemia presenting with high-grade fever were included, with 14 (58.3%) males, mean duration of fever 7.7 days (4–18 days), and 09 (37.5%) having temperature >103°F. The mean hemoglobin (Hb) was 8.15 g/dL (3.7–11.1 g/dL), the mean corpuscular volume (MCV) was 111 ± 7.8 fL, 18 (75%) had unconjugated hyperbilirubinemia, the mean lactate dehydrogenase (LDH) was 814 ± 24 IU/L, and 21 (87.5%) had low B12 or folate levels. Most showed good therapeutic response to B12 or folic acid with defervescence in 1–5 days (mean 2.6 days) and improvement in lab parameters in 1 week. The study population was divided into those with temperature ?103°F, and temperature <103°F it was seen that there was a significant association (p < 0.05) with leucocyte count of ?3000/cumm, and MCV ?110 fL, in patients with temperature ?103°F Conclusion: Megaloblastic anemia should be considered in the differentials of a patient presenting with a febrile illness with no clinical localization and a negative initial fever workup. Early identification and prompt therapy of this easily treatable disorder are very essential.

Etiological causes and epidemiological characteristics of patients with occupational corneal foreign bodies: A prospective study in a hospital-based setting in India

Purpose: Corneal foreign bodies (CFBs) due to occupational exposure have been largely ignored in Indian literature, especially nonmetal workers. Our study looks at a broad range of occupations and settings that contribute to CFB in our local Indian population. The study objective was to determine the occupations, level of education and demographics of patients presenting with CFB acquired during occupational work. Methods: Prospective hospital-based study at a tertiary eye hospital in Gurgaon, Haryana, India, within duration of 9 months. Patients presenting with CFB were asked a set of questions relating to their occupation, level of education, understanding of the potential complications of CFB, and demographics. Results: A total of 83 patients were included in the study. CFB were attributed only to males. 66% of patients were in the age group of 14--29 years. 30% of patients were in the age group 30--44 years and 4% of patients were between 45 and 60 years old. The metal work industry was responsible for 47% of presentations. The construction industry was responsible for 27% of presentations. Electricians and carpenters combined were responsible for 10% of presentations and 17% of presentations occurred in other sectors. Conclusion: CFB occur across a number of occupations in the construction industry, not just metallic workers. Among a population that is generally poorly educated and have nominal understanding of the impact that CFB can have on vision, occupational hazard education is necessary to address this problem.

Superbugs causing ventilator associated pneumonia in a tertiary care hospital and the return of pre‑antibiotic era.

The rise in super bugs causing Ventilator‑Associated Pneumonia (VAP) is a major cause of mortality and morbidity despite recent advances in management owing to the looming ‘antibiotic apocalypse’. The aetiology and susceptibility pattern of the VAP isolates varies with patient population, type of intensive care unit (ICU) and is an urgent diagnostic challenge. The present study carried out for a period of one year in a tertiary care hospital, enrolled patients on mechanical ventilation (MV) for ≥48 hrs. Endotracheal aspirates (ETA) from suspected VAP patients were processed by semi quantitative method. Staphylococus aureus, members of Enterobacteriaceae were more common in early onset VAP (EOVAP), while Nonfermenting Gram negative bacilli (NFGNB) were significantly associated with late onset VAP (LOVAP). Most of the isolates were multi drug resistant (MDR) super bugs. With limited treatment options left for this crisis situation like the pre‑antibiotic era; it is an alarm for rational antibiotic therapy usage and intensive education programs.

Interleukin-6 (IL-6)-597 A/G (rs1800797) & -174 G/C (rs1800795) gene polymorphisms in type 2 diabetes.

Background & objectives: Diabetes is a metabolic pro-inflammatory disorder characterized by chronic hyperglycaemia and increased levels of circulating cytokines suggesting a causal role for inflammation in its aetiology. In order to decipher the role of interleukin-6 (IL-6) in type 2 diabetes mellitus (T2DM) we analyzed two promoter polymorphisms -597 A/G (rs1800797) and -174 G/C (rs1800795) in T2DM cases from north India, and in healthy controls. methods: DNA was isolated from venous blood samples of T2DM patients (n=213) and normal healthy controls (n=145). Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed after biochemical analysis. The genotypic and allelic frequency distributions were analyzed. Results: The clinical/biochemical parameters of T2DM cases when compared to controls showed a significant difference. No significant association was observed with -597A/G polymorphism while, -174 G/C showed a highly significant association (P<0.001). In haplotypic analysis, combination of -597G*/-174C* showed significant association (P=0.010). Interpretation & conclusions: Our data suggest that IL-6 gene polymorphisms play a prominent role in T2DM disease susceptibility in population from north India.

Mixed pulmonary infection in an immunocompromised patient: A rare case report.

Patients who are immunocompromised are predisposed to a variety of common and uncommon pulmonary infections. We report a case of mixed pulmonary infection by drug resistant tuberculosis with a nocardiosis in a 49-year-old man who was a known case of chronic obstructive pulmonary disease, on prolonged corticosteroid use with diabetes mellitus. Chronic use of corticosteroids is a predisposing factor for opportunistic infections, such as nocardiosis or tuberculosis. Since such a mixed infection is rare, maybe a combined approach to therapy early in the course of disease would be effective in such cases.

Colonic Strictures after Necrotizing Enterocolitis in Infants: Case Series.

The fate of neonates with necrotizing enterocolitis is variable, with colonic strictures being one rare phenomenon after the insult. We describe here two infants with colonic strictures, which developed secondary to neonatal necrotizing enterocolitis. Infants recovered or in the process of recovery after it should be investigated for possibility of development of colonic strictures.

Preliminary studies on CD36 gene in type 2 diabetic patients from north India.

Background & objectives: The greater tendency to diabetes in Indians may be due to genetic factors in addition to environment and diet. CD36, a class B scavenger cell surface receptor mediates internalization of oxidized low density lipoprotein (Ox-LDL) leading to the formation of macrophage foam cells. CD36 deficiency is related to phenotypic expression of the metabolic syndrome, frequently associated with atherosclerotic cardiovascular diseases resulting in raised levels of glucose thereby contributing to type 2 diabetes (T2DM). Therefore, the association of human CD36 gene mutation to T2DM needs investigation. We undertook this study to investigate CD36 gene status in north Indian subjects by screening for the deletion of exons 3, 4 and 5 and certain polymorphisms. Methods: Clinical characteristics were compared between 300 T2DM patients and 100 healthy controls. Deletion analysis was carried out for exons 3, 4 and 5 of CD36 gene in 300 T2DM patients using PCR and agarose gel electrophoresis. Genotype analysis for two polymorphisms 478C>T and delAC in exons 4 and 5 respectively was carried out using PCR-RFLP method. Results: Biochemical parameters such as fasting and post-prandial glucose levels, total cholesterol, LDL-cholesterol and blood pressure were slightly raised in the T2DM patients when compared with controls with lowered HDL-cholesterol. No exonic deletion was observed in the 300 patients and 100 controls screened. All individuals were found to be homozygous (CC and -/-) for the two polymorphisms studied. Interpretation & conclusions: Although no exonic deletion was found in T2DM patients, our study suggests that all 15 exons need to be screened for mutations which lead to CD36 deficiency. Genotyping studies of the two SNPs in the CD36 gene confirmed the absence of exons 4 and 5 deletion. This is perhaps the first report from India suggesting that CD36 is one of the several important genes that need to be explored in relation to T2DM.

Childhood Intussusception: A Prospective Institutional Study at BPKIHS.

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. The present study deals with the presentation, management and outcome of children presenting with intussusception at the Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Materials and Methods: Forty-seven children presenting at Department of Surgery, B. P. Koirala Institute of Health Sciences over a 5-year period were prospectively studied. Results: There were 27 (58.6%) males and 20 (41.4%) females, with male-to-female ratio of 1.4:1. The ages ranged from 2 months to 13 years, with a median age of 30 months. The mean duration of presentation was 10.7 ± 30.66 days (range 1-180 days). The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 10 (21%) of the cases. Surgical exploration was done in 42 (89.3%) patients. The commonest lead point was non-specific hyperplastic lymph nodes, occurring in 22 (54.3%), followed by idiopathic variety (16.6%), Meckel’s diverticulum (9.5%), ileocaecal junction (7.1%), submucous lipoma (4.7%), Non- Hodgkin’s lymphoma (4.7%), appendix (2.3%) and a mucosal polyp (2.3%). Overall mortality rate was 6.3%. Conclusion: The presenting age group and the time of presentation are higher than other studies. The mortality rate of 6.3% is comparable to other studies in the developing world. Earlier presentation could have avoided surgery, with a higher possibility of cases being managed conservatively.

Pediatric femoral hernia.

Pediatric femoral hernias account for less than 1% of all groin hernias. Pediatric femoral hernias are rather uncommon more so in males, often overlooked, misdiagnosed and treated as inguinal hernia. Femoral hernia masquerading as inguinal hernia in a seven year old male is reported along with review of relevant literature.

Association of IL-4 and IL-1RN (receptor antagonist) gene variants and the risk of type 2 diabetes mellitus: A study in the north Indian population.

Background: Inflammation is a key event closely associated with the pathophysiology of type 2 diabetes mellitus (T2DM). Association of genetic polymorphisms of inflammatory cytokines with T2DM is largely unknown. Our objective was to investigate the relationship of polymorphism of IL-1RN and IL-4, two important biomarkers of inflammation, with the risk of T2DM. Setting and Design: We recruited 120 clinically diagnosed T2DM patients and 150 normal healthy controls for this study in order to evaluate the nature of polymorphisms of IL-1RN and IL-4. Materials and Methods: Genomic DNA was isolated from the blood of all subjects, and the variable number of tandem repeat (VNTR) polymorphisms of IL-1RN and IL-4 genes was identified by polymerase chain reaction. Statistical Analysis Used: Genotype distribution and allelic frequencies were compared between patients and control group. Means, as well as odds ratios (ORs) with 95% confidence intervals (CI), were calculated using SPSS software (version 11.5). Results: Our study revealed that distribution of both IL-4 and IL-1RN (VNTR) gene polymorphisms were significantly associated with T2DM subjects. We, however, failed to find any association of gene-gene (IL-4 and IL-1RN) interaction with T2DM. Conclusions: Both IL-4 and IL-1RN (VNTR) gene polymorphisms were significantly associated with T2DM subjects. This may suggest that the genetic polymorphisms of IL-4 and IL-1RN genes could serve as susceptibility indicators for T2DM in the Indian population, but the actual mechanism of these associations will require more elaborate investigations. Lack of association of gene-gene (IL-4 and IL-1RN) interaction with T2DM may indicate the independent nature of influence of both these genes on the risk of T2DM.

Correlation of prostate volume with international prostate symptom score and quality of life in men with benign prostatic hyperplasia.

The aim of this study was to correlate the prostate volume with international prostate symptom score (IPSS) and quality of life (QOL). Hundred consecutive patients diagnosed as having benign prostatic hyperplasia were included. All patients were interviewed using standardized questionnaires for International Prostate Symptom Score, which include one single disease-specific quality of life question. Transabdominal ultrasonogram was used to assess the prostatic volume. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age and median duration of symptom was 67.5 years and 12.0 months respectively. The mean volume of prostate was 42.5 cm3. Most of the patients had severe symptoms with mean IPSS of 23.5 and single disease-specific QOL score of 5.2. The correlation between the prostate volume and age, IPSS, and QOL score were not statistically significant except for two domains; incomplete emptying and nocturia that appear to be correlated with prostate volume. The correlation between IPSS and QOL score was strong. Similarly, correlation between QOL score and age was significant but weak. In conclusion, prostate volume had no correlation with age, symptom score, and quality of life score. So prostatic size should not be an only and important consideration; moreover, we should assess the impact of symptoms while treating the cases.

Port exteriorization appendectomy: is it the future?

The time honoured surgical procedure open appendectomy seems to be on the decline, it may be replaced in the modern era by laparoscopic appendectomy ("in appendectomy") performed with three trocars, or by the port exteriorization appendectomy ("out appendectomy") which can be done with two ports or even one. These techniques combine the benefits of decreased tissue trauma and operative time in addition to other advantages of minimal invasion. We conducted this study to know the effectiveness of Port Exteriorization Appendectomy, to analyze its complications and to assess the conversion rate. A one year prospective study consisted of fifty cases; a combination of emergency and elective group. They were operated under general anaesthesia and different variables were documented. Mean operative time, conversion rate, hospital stay, complications and patient satisfaction. There were 27 females with the (F: M) ratio of 1.17:1. The operative time of 23.3 mins, conversion in 4 (8.0%) patients and 2.4 days of hospital stay contributed to 86.0% operative success rate. Surgical site infection was seen in 5 (10.0%) patients and one (2.0%) developed pelvic abscess. On analysis of the satisfaction level, 44(93.6%) were completely satisfied and one (2.1%) patient seemed disappointed with the technique for cosmesis though, 42 (89.3%) remained completely satisfied and 5(10.7%) didn't like their scars. Port exteriorization appendectomy's efficacy can be verified by 86.0% success rate, operative time of 23.3 mins, indoor stay of 2.4 days, and minimal undesirable sequlae. However, more authentic results could be obtained if this technique is compared to open or laparoscopic appendectomy in a well designed randomized controlled clinical trial.

Role of serum C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in Nepalese population.

Various diagnostic modalities have been reported to influence the negative appendicectomy. C-reactive protein (CRP), an acute phase reactant, may improve the accuracy of diagnosing acute appendicitis. The present study was undertaken to evaluate the utility of CRP as a diagnostic tool among patients clinically suspected to have acute appendicitis. The role of total leukocyte (WBC) count was also studied. A total of 145 diagnosed cases of acute appendicitis were studied over a period of one and half years. CRP was raised in 91 cases and was normal in 54 cases. The sensitivity and specificity of CRP estimation in diagnosing appendicitis was 74.8% and 66.7% respectively and the sensitivity and specificity for total WBC count was 78.6 and 54.8% respectively. The present study suggests that we cannot rely wholly on CRP or on WBC count for operative decision. Clinical judgment is still the best modality for the diagnosis and operative management of acute appendicitis. It seems wiser to use active observation, which should identify most patients with non-specific pain and reserve operation for those who need it most.

Oxidative stress in patients with benign prostate hyperplasia.

Benign Prostate Hyperplasia (BPH) is a common health problem in aging male. Free radicals and Reactive Oxygen Species (ROS) are produced in overwhelming quantity with advancement of age. When in oxidative stress, these reactive species cause extensive damage to various organ in the body, may be associated with pathogenesis of BPH also. This study aimed at assessing Malondialdehyde (MDA), the marker of lipid peroxidation and anti-oxidants e.g. alpha-Tocopherol and Ascorbate status in plasma in BPH patients. Forty eight (n=48) cases of BPH and forty six (n = 46) healthy age matched controls were enrolled. Plasma MDA level showed 4.81+/-1.87 nmol/ml in cases compared to 3.69+/-1.56 nmol/ml in healthy controls (p<0.001). There were significant decrease in plasma alpha-Tocopherol and ascorbate level which were 0.85+/-0.12 mg/dl and 0.93 +/- 0.13 mg/dl in cases compared to 1.37+/-0.31 mg/dl and 1.44+/-0.38 mg/dl in healthy controls respectively. Inverse correlation of plasma MDA with alpha-Tocopherol (r = -0.09, p>0.05) and Ascorbate (r =-0.51, p=0.008) was found in BPH patients. There was mild elevation of PSA in BPH patients compared with control but was not statistically significant. Thus, our study showed the evidence of association of oxidative stress in BPH patients.

Change in urinary symptoms and quality of life in men with benign prostatic hyperplasia after transurethral resection of prostate.

The aim of this study was to determine the improvement in symptoms and quality of life in men with Benign Prostatic Hyperplasia (BPH) after transurethral resection of prostate (TURP). Fifty consecutive patients fit for undergoing TURP for BPH were included in this study. All patients were assessed prior to definitive surgical treatment using standardized questionnaires of international prostate symptom score (IPSS) which includes single disease-specific quality of life (QOL) score. Follow up of these patients was done at three months with same questionnaires. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age and duration of symptom was 68.3 years and 26.7 months respectively. The average volume of prostate was 46.1 cm3. Preoperative IPSS and QOL score were 23.4 and 5.2 respectively; 56.6% of the score was contributed by obstructive symptoms. At three months follow up, the mean IPSS reduced down to 7.9 and QOL score improved to 1.5. The average change in IPSS and QOL score were 15.6 and 3.6; these changes were statistically significant and correlated with preoperative symptom severity. Most of the patients presented with severe symptom associated with decreased QOL. After TURP, there was significant improvement in IPSS and QOL scores. The improvement was graded as good out come and strongly related to preoperative symptom severity.

Factors influencing mortality in perforated duodenal ulcer following emergency surgical repair.

Duodenal perforation is a common abdominal catastrophe with excellent outcome if prompt resuscitation and surgical repair of perforation are done. The aim of this study was to identify factors associated with death after surgery in patients with duodenal perforation. One hundred and forty-five patients who underwent Graham's patch repair for perforated duodenal ulcer between 14 April 2002 and 31 December 2004 were studied. The mean age was 45.99 years and 61 patients (42.07 %) were referrals. There were 124 (85.52 %) males and 21 (14.48 %) females. There were 10 deaths (6.9 %). The mean time delay was 2.46 days. It was 2.37 days in survivors, 3.7 days in non-survivors. The time delay was 3.25 days for females and 3.13 days for patients referred from another hospital. The mortality was significantly associated with time delay between perforation and operation (p<0.01), presence of co-morbid conditions (P<0.04), respiratory rate (p<0.02), raised blood urea (p<0.01) and serum creatinine (p<0.001), size of perforation (p<0.005), amount of peritoneal fluid (p=0.003) and requirement of postoperative intensive care unit support (p=0.003). Time delay between perforation and operation, preoperative blood urea and serum creatinine, size of perforation and amount of peritoneal fluid, presence of co-morbid conditions and need for post operative ICU support are the important predictors of outcome after emergency surgery for duodenal perforation.

Splenic epidermoid cyst.

Splenic epidermoid cyst is a rare cystic disease affecting the spleen. We report a young male who presented with a painless abdominal lump. Ultrasonography and CT scan of abdomen showed a huge cystic lesion of obscure origin. At laparotomy a huge cyst was found to be arising from the superior pole of the spleen, and its removal necessitated splenectomy. Histopathological findings were consistent with splenic epidermoid cyst. The aetiopathology and different treatment modalities of splenic cysts are discussed.

Gall bladder carcinoma: stroke as first manifestation.

Clinical presentation of gall bladder carcinoma with distant metastasis is extremely rare. We report a 73-year-old lady who presented with right-sided hemiparesis. CT scan showed a left frontal lobe tumor. Excision of the tumor resulted in improvement of neurological functions. Further workup revealed a gall bladder mass with liver nodules.

Chest radiographs and their reliability in the diagnosis of tuberculosis.

Radiology plays an important role in the diagnosis of pulmonary tuberculosis. Many medical practitioners believe in and rely primarily on the chest x-ray for the diagnosis of pulmonary tuberculosis. This study attempts to evaluate the reliability and validity of chest radiographs. This study was carried out in the tuberculosis clinic of BPKIHS. 75 radiographs were chosen for the study and viewed by 25 physicians of varying qualifications. Their findings were compared with the gold standard. The overall sensitivity and specificity was 78% and 51% respectively. There was poor agreement between the best physician and the best radiologist. This study has demonstrated an unsatisfactory sensitivity and specificity of chest x-rays in the diagnosis of pulmonary tuberculosis. The over-diagnosis and over-treatment due to chest x-rays could lead to an unmanageable burden on the resources of a poor country like Nepal. Private practitioners should be made aware about the importance of bacteriological diagnosis of tuberculosis before initiating drug therapy.

Tuberculous splenic abscess--a case report and review of literature.

Splenic abscess due to tuberculosis is a rare condition and is mostly diagnosed in immuno-compromised hosts. A case of tuberculous splenic abscess detected incidentally after splenectomy without any underlying disease is reported in an immuno-competent patient.