Chief registrars: Leading in a time of COVID-19.

The NHS is currently in the midst of a global health crisis that requires rapid action from its staff and systems. The Royal College of Physicians' chief registrars, in their role as middle leaders that bridge the gap between junior doctors and senior leadership in NHS trusts nationwide, are uniquely positioned to respond to the COVID-19 crisis. Our strategies fall into three overlapping categories: our roles as middle leaders, developing effective communication techniques and promoting staff wellbeing. We discuss lessons of good leadership in a time of crisis, from embracing new ways of working and new technologies, to utilising professional networks to drive change, to providing tools to support the wellbeing of the colleagues we both lead and care for. The lessons of our initial response are being shared across our national network. We also hope that the novel approaches we have developed will inform the practice of future middle leaders.

Bilateral interstitial keratitis and granulomatous uveitis of tubercular origin.

BACKGROUND: Tuberculosis (TB) is an important cause of ocular morbidity. Establishing a diagnosis may be difficult in some situations especially with unusual presentation. We report case of bilateral interstitial keratitis (IK) associated with anterior uveitis as a presenting feature of ocular TB from India. METHODS: A 17-year-old woman presented with diminution of vision in both eyes. Slit lamp biomicroscopy showed central bilateral IK and active granulomatous uveitis. Laboratory investigations revealed raised erythrocyte sedimentation rate (50 mm/hr) and positive tuberculin test (22 mm induration) and QuantiFERON-TB Gold test (3.34 IU/mL), with no foci of systemic infection. RESULTS: Presumptive diagnosis of ocular TB was made. The patient was started on antitubercular therapy and topical steroids, after which symptoms and signs resolved. There was no recurrence of the disease for 1 year after completion of antitubercular therapy. CONCLUSIONS: Bilateral central IK with granulomatous uveitis is probably related to the presence of tubercular antigen in aqueous humor. Positive QuantiFERON-TB Gold test is useful for initiating the antitubercular treatment where unusual presentation is encountered.

Rosai-dorfman with bilateral involvement of lacrimal sac as extranodal disease.

A 45 year old female presented with painless swelling over the inner side of both eyes since one year. Magnetic resonance imaging (MRI) scan revealed well defined lesions in the bilateral lacrimal sac area with extension along the naso-lacrimal duct. Systemic work up showed polyclonal hyperglobulinemia, raised erythrocyte sedimentation rate (ESR) and anemia. The patient also had subcutaneous swelling in thoracic area over back. The histopathology of the bilateral excised tumor and fine needle aspiration cytology of thoracic swelling was consistent with features of Rosai-Dorfman syndrome.

A rapidly developing lung mass diagnosed as desmoplastic small round cell tumor.

We present a case of a young male who presented with complaints of fever along with cough and sputum. He was diagnosed with having right pleural effusion. He was already taking anti-tubercular therapy for one month before presentation. He was started on intravenous antibiotics and continued on anti-tubercular therapy in our hospital, based on his high leukocyte count, pleural fluid analysis, and ultrasonographic report of multiple hypoechoic areas in the liver. His symptoms continued to worsen and he subsequently developed mediastinal widening and a left lung mass. Commuted tomography (CT)-guided biopsy of the lung mass revealed a desmoplastic small-round-cell tumor. Desmoplastic small-round-cell tumor is a rare and aggressive tumor, which presents rarely as a mediastinal and lung mass. This tumor has very poor prognosis.

Rare association of Visceral leishmaniasis with Hodgkin's disease: A case report.

We present here a case of young male with complaints of fever and swelling in the neck for eight months. History of progressive weakness associated with weight loss was present. Physical examination revealed pallor, multiple enlarged cervical lymph nodes and hepatosplenomegaly. Investigations showed pancytopenia, hyperglobinemia and Leishman-Donovan bodies on bone marrow aspiration. Serological test confirmed diagnosis of visceral leishmaniasis. However, cervical lymph node aspiration and biopsy were suggestive of Mixed cellularity Hodgkin's disease. This made it a very rare case of Leishmaniasis as an opportunistic infection in a patient of pre-chemotherapy Hodgkin's disease. There was marked improvement in haematological profile and regression of hepatosplenomegaly with Amphotericin B treatment followed by favourable response to chemotherapy. The case emphasizes the suspicion for leishmaniasis as a masquerader and as an opportunistic infection in haematological malignancies.

A rare case of reversible acquired AA-type renal amyloidosis in a chronic filariasis patient receiving antifilarial therapy.

Lymphatic filariasis is a major health problem in India with a large number of patients tending to be asymptomatic. In the Southeast and South Asian regions, Wuchereria bancrofti is the most prevalent parasite, causing filariasis in 99.4% of cases. While kidney involvement is a rare event in chronic filariasis, this case is unique because AA-type renal amyloidosis occurs in chronic W. bancrofti infection. We present here a unique case of lymphatic filariasis. The patient, a 25-year-old male who was previously diagnosed with right lower limb filarial lymphedema and had undergone lymphovenous anastomosis, was admitted for evaluation of persistent nephrotic-range proteinuria. Autoimmune markers in the form of anti-nuclear antibodies, anti-double-stranded DNA and anti-neutrophil cytoplasmic antibody were negative; C3 was normal. Urine analysis revealed inactive sediment with moderate proteinuria. Both serum and urine electrophoresis were negative for paraproteins and bone marrow aspirate and biopsy were normal. Evidence of active filarial infection was established on the basis of microfilariae in the peripheral smear and a positive W. bancrofti antigen test. Kidney biopsy revealed renal amyloidosis when stained with Congo red and anti-AA immunostain. The patient's proteinuria improved on conservative management with angiotensin-converting enzyme inhibitors and a course of antifilarial drugs. His proteinuria returned to <1 g/24 h with normalization of renal function and no significant proteinuria on periodic follow-up at 6-month and 1-year intervals. Repeat kidney biopsy after 1.5 years showed regression of amyloidosis. Repeat demonstration of filarial antigen and microfilariae in the peripheral smear were negative on multiple occasions during the follow-up period. Although various chronic infections can lead to secondary renal amyloidosis, this is the first case reported in world literature where secondary amyloidosis developed as a complication of chronic filarial infection due to W. bancrofti. This is probably also the first case reported in world literature where renal amyloidosis has an etiological association with W. bancrofti infection and where patient symptoms improved with antifilarial and antiproteinuric management.

A series report of autoimmune hypothyroidism associated with Hashimoto's encephalopathy: an under diagnosed clinical entity with good prognosis.

Thyroid dysfunctions may be accompanied by numerous neurological and psychiatric disorders. The most well-known is cognitive impairment and depression in hypothyroid patients, as well as an increased risk of cerebrovascular accidents. A separate, although a rare entity, is Hashimoto's encephalopathy. Unlike encephalopathy associated with other conditions, management in Hashimoto's encephalopathy highly responds to steroid treatment and may be associated with normal thyroid profile at presentation. Hashimoto's encephalopathy, while rare, may have been under-recognised since its clinical presentation overlaps several more common disorders, such as depression, seizures or anxiety. We present two cases of hypothyroidism with peculiar presentation. The first case has rapidly progressive neurological dysfunction, normal thyroid function at presentation, normal MRI finding and responds to steroid treatment. The second case has a subacute progressive neurological deterioration with elevated thyroid-stimulating hormone titre at presentation. Both these cases are known hypothyroidism on regular thyroxin replacement therapy with elevated anti-thyroid peroxidase antibodies. We conclude that Hashimoto's encephalopathy can present with a wide spectrum of neurological illnesses in the setting of hypothyroidism. Thyroid status may vary from hypothyroid, normothyroid to even hyperthyroid. This condition usually has an abnormal electroencephalography (EEG) background and usually responds to high dose steroids.

Antinutritional factors and in vitro protein digestibility of improved haricot bean (Phaseolus vulgaris L.) varieties grown in Ethiopia.

The antinutrient (raffinose oligosaccharides, tannins, phytic acid and trypsin inhibitors) composition and in vitro protein digestibility of eight improved varieties of Phaseolus vulgaris grown in Ethiopia were determined. Stachyose was the predominant alpha-galactosides in all haricot bean samples. Raffinose was also present in significant quantities but verbascose, glucose and fructose were not detected at all in the samples. The concentrations observed for the protein digestibility and antinutritional factors, varied significantly (P<0.05) between varieties investigated in this study. Mean values for protein digestibility ranged from 80.66% (in Roba variety) to 65.64% (in Beshbesh variety). Mean values for raffinose, stachyose, sucrose, trypsin inhibitors, tannins and phytic acid were 3.14 mg/g, 14.86 mg/g, 24.22 mg/g, 20.68 TUIx10(3)/g, 17.44 mg, catechin equivalents/g and 20.54 mg/g respectively. Statistical analyses of data revealed that antinutritional factors and protein digestibility were influenced by variety (genotype). Relationships between antinutritional factors and protein digestibility were also observed. The possibility of selecting varieties to be used for large-scale cultivation in Ethiopia on the basis of these data is discussed. Among the improved varieties studied, Roba, Redwolaita, Mexican and Awash were found to be the best food and export type of haricot beans in the Ethiopian context, because of their higher protein digestibility, lower antinutrtional factors and other beneficial nutritional parameters. Roba variety can be used by local food processors for the production of value-added bean-based products especially to combat the problem of protein energy malnutrition and related diseases which are very common in developing countries.