A rare case of duodenal carcinoid presenting as ectopic Cushing’s syndrome

ACTH-dependent Cushing syndrome (CS) due to an ectopic source is responsible for approximately 10-15% cases of Cushing’s syndrome. It is associated with various tumors such as small cell lung cancer and well-differentiated bronchial or gastrointestinal neuroendocrine tumors. Many a times ectopic ACTH production is difficult to manage, and identification of the source may take many years. Hormonal diagnostics include assessments in basic conditions as well as dynamic tests, such as the high-dose dexamethasone suppression test and corticotrophin releasing hormone (CRH) stimulation test. Treatment selection depends on the type of tumor and its extent. In the case of neuroendocrine tumors, the main treatments are surgery and administration of somatostatin analogues or bilateral adrenalectomy in refractory cases and if the source remains unidentified. Here, we report a case who presented with features of Cushing’s syndrome which eventually through workup led us to a diagnosis of duodenal carcinoid producing ectopic ACTH which is extremely rare and was successfully treated.

A clinical and microbiological profile of urinary tract infection in patients with chronic kidney diseases

Background: Urinary tract infections (UTIs) are a major public health problem in terms of morbidity and financial cost in CKD patients in India. The resistance pattern of community acquired uropathogens in CKD patients has not been extensively studied. Thus, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community acquired UTIs.Methods: It is a cross sectional study conducted in a tertiary care hospital involving 65 chronic kidney disease patients with UTI who attended general medicine OPD and those admitted in wards after fulfilling the inclusion and exclusion criteria, after obtaining written informed consent. Blood sample and urine samples were collected from these patients and sent for blood analysis, urine analysis and urine culture and sensitivity.Results: Among 65 CKD participants with UTI who were studied, E. coli (47.7%) and K. pneumoniae (15.4%) were the most common isolates which were sensitive in order of colistin, polymyxin B, meropenem (carbapenem) and less sensitive to other commonly used antibiotics.Conclusions: The main purpose of this study was to find the various common local uropathogens in CKD patients and their antibiotic profile which will help in formulating antibiotic therapies. As previously stated, there are very few studies regarding profile and management of UTI in CKD patients. Hence this study can throw some light into this area.

Evaluation of hepatocellular dysfunction and its association with severity in dengue patients

Background: Dengue is a mosquito-borne infection that in recent years has become an important disease of international public health concern. Dengue virus infections and illness when symptomatic, that patients tend to present with a significantly wide variety manifestations. The aim of the study was to evaluate liver dysfunction in patients with dengue infections.Methods: The present study was undertaken as an observational cross-sectional study the period June 2017 to December 2018. The details of all patients with serologically proved dengue fever admitted in the hospital were reviewed. Data including routine blood count, liver function test (LFT), prothrombin time (PT), activated partial prothrombin time (APTT), abdominal ultrasonography was studied. Statistical analysis: Data was analyzed using SPSS version 21.0. Difference between proportions was tested by using chi square test. Pearson correlation coefficient was used to measure linear correlation between two continuous variables. A p value <0.05 was consideredstatistically significant.Results: Majority of the study participants were in the age group of 16-30 years (57.5%) and were males (64.5%). Fever, Headache and joint pain were the most common symptoms noted among the study participants. Majority of the study participants were found to have elevated levels of SGOT (75.3%), SGPT (64.2%) levels and lower levels ofserum albumin (68.6%) on evaluation. Statistically significant association was observed between elevated liver enzymes and presence of features of dengue haemorrhagic fever.Conclusions: Considerably high proportion of patients with dengue infection were found to have hepatic dysfunction in the form of deranged liver enzymes.

Pattern of use of antibiotics in hospitalized patients in the medicine department of a tertiary care hospital.

Background: (1) To assess pattern of antibiotic use among in-patients of medicine unit in a tertiary care hospital, (2) to determine the frequency of adverse drug reactions (ADR) among the inpatients receiving antibiotics in medicine unit. Methods: The study was prospective and based on the daily review of patient records for 2 months (June, July) of study period, including all the inpatients of medicine unit 1 receiving antimicrobials. The general information of the patients, infection, antimicrobial use, culture and sensitivity reports, concomitant disease, concomitantly administered drugs, as well as clinical response were collected. The prescribed antimicrobials were correlated with the patient’s culture and sensitivity report. The number of defined daily doses (DDDs) administered per patient was calculated for each antimicrobial prescribed as per WHO anatomical therapeutic chemical classification. The ADR observed during the study were assessed using WHO causality analysis. The economic burden of the antimicrobial used was analyzed using average cost of antimicrobial per patient. The study was approved by the Institute Ethics Committee. Results: The antimicrobials that are commonly used as per total drug use (DDDs) are ceftriaxone followed by doxycycline and metronidazole. The antimicrobials account for 58.6% of cost spent on drugs for inpatients. Four antimicrobial related ADR were reported during the study period. Conclusion: Ceftriaxone, doxycycline, and metronidazole are commonly used antibiotics and significant proportion of the cost of drugs is spent for antimicrobials in a medicine unit.

Split-hand/feet malformation in three tamilian families and review of the reports from India.

Split‑hand/foot malformation (SHFM) is a rare condition which can be either syndromic or nonsyndromic. We report three unrelated pedigrees, one with autosomal dominant (AD) inheritance and the other two with autosomal recessive (AR) pattern. We also briefly review the published reports from India.

Fever of unknown origin in a patient of systemic onset juvenile idiopathic arthritis.

Hemophagocytic lymphohistiocytosis is a potentially fatal condition characterized by pathologic immune activation, which can complicate infections, childhood systemic rheumatologic diseases and malignancies. Here we report a case of reactive hemophagocytic lymphohistiocytosis [macrophage activation syndrome] complicating systemic onset juvenile idiopathic arthritis, which was treated successfully with dexamethasone and cyclosporine. Reactive hemophagocytic lymphohistiocytosis or macrophage activation syndrome should be considered in patients of juvenile idiopathic arthritis with prolonged fever of unknown origin and cytopenias. Early diagnosis with high index of suspicion and prompt, aggressive treatment are needed for successful outcomes.

Lack of association between Glu(298) asp polymorphism of endothelial nitric oxide synthase (eNOS) gene and coronary artery disease in Tamilian population.

OBJECTIVE: Glu298 Asp polymorphism of endothelial nitric oxide synthase (eNOS) gene has been recently implicated as a genetic marker for coronary artery disease (CAD) in some studies. There is no information on the prevalence of this polymorphism and its relationship with CAD in south Indian population. METHODS: A case control study was performed for the determination of the influence of Glu298 Asp polymorphism of eNOS gene in Tamilian population of south India. The study subjects comprised of 100 angiographically proven CAD patients and 100 age- and sex-matched volunteers asymptomatic for CAD, with a low coronary risk score. Genotyping of the eNOS gene was done by the polymerase chain reaction-restriction fragment length polymorphism (PCR RFLP) method. RESULTS: The genotype distribution was not significantly different between CAD (GG; 72, GT; 26, TT; 2) and control subjects (GG; 79, GT; 18, TT; 3). The corresponding allele frequencies were G 0.85, T 0.15 and G 0.88, T 0.12, respectively. The odds ratio for the association of CAD with the Asp variant failed to achieve statistical significance (OR = 0.66; 95% CI: 0.11-4.04, P = 1.0). CONCLUSION: No significant association was observed between the Glu298 Asp polymorphism and CAD in this population group.

A hospital-based study of splenomegaly with special reference to the group of indeterminate origin.

In any study there remains a proportion of cases, about 25-40%, where cause of splenomegaly is not identified on usual evaluation, that is labelled as indeterminate group. The aim of this study was to evaluate various causes of splenomegaly. Thereafter the patients with splenomegaly of indeterminate origin were to be re-evaluated with detailed investigations (for the cause of splenomegaly). Causes of splenomegaly were looked into 100 adult patients with splenomegaly, admitted over a period of ten months in a teaching hospital in South India. Patients having ascites were excluded from the study. Malaria was the commonest cause of splenomegaly, observed in 22 patients. Other causes, in order of importance, were chronic myeloid leukaemia (n=11), non-cirrhotic portal fibrosis (n=9), enteric fever (n=9), cirrhosis of liver (n=8) and hyper-reactive malarial splenomegaly also called as tropical splenomegaly syndrome (n=7) and so on. Hyper-reactive malarial splenomegaly was the commonest cause (7 of 24 patients) of massive splenomegaly. Twenty-three patients had splenomegaly of indeterminate origin ie, cause could not be detected on first assessment. Detailed re-evaluation with repeat investigations including liver biopsy revealed the causes as follows: Hyper-reactive malarial splenomegaly -7 (30.4%), non-cirrhotic portal fibrosis - 4 (17.4%), cirrhosis of liver - 4 (17.4%) and iron deficiency anaemia - 5 (21.7%). In 3 patients (13.0%), no diagnosis could be arrived at despite best efforts. Obscure splenomegalies may be due to conditions like hyper-reactive malarial splenomegaly, non-cirrhotic portal fibrosis, iron deficiency anaemia, and even cirrhosis of liver, while malaria is still the most important cause of splenomegaly in India. Whereas the overall incidence of hyper-reactive malarial splenomegaly was only 7% in this study, it stood as the leading cause (29.2%), when analysed among patients with massive splenomegaly. Liver biopsy should be performed in all cases of obscure splenomegaly to arrive at the final diagnosis.