Unusual manifestations of extra-pulmonary tuberculosis: a pictorial essay.

Purpose: Tuberculosis is quite common in India. About 40% of all Indians are infected with mycobacterium tuberculosis, with 2.5 million active tuberculosis cases. Tuberculosis primarily affects the lungs, but it can affect any organ. Extra-pulmonary involvement occurs 15-20% of cases in immune-competent patients and in more than 50% in HIV patients. The most common extra-pulmonary sites are lymph nodes, pleura, abdomen, genitourinary tract, skin, joints and bones, or meninges. Case reports: In this pictorial review article we present 8 atypical cases of tuberculosis and describe their imaging features and histopathology. Conclusions: Extra-pulmonary tuberculosis can affect virtually any organ and can mimic various inflammatory and neoplastic disorders apart from other infective conditions. A strong index of suspicion is required particularly in those countries endemic to tuberculosis.

Ultrasound imaging for the differential diagnosis of periapical lesions of endodontic origin in comparison with histopathology - a systematic review and meta-analysis.

BACKGROUND: Differentiating periapical lesions is important for treatment planning and subsequent treatment outcome. OBJECTIVE: To assess the diagnostic accuracy of ultrasound imaging for the differentiation of periapical lesions in comparison with histopathology. METHODS: PubMed, Scopus, Embase, Web of Science and ProQuest databases were searched for clinical studies published until June 2020 that evaluated the use of ultrasound (US) imaging for differential diagnosis of periapical lesions and used histopathology as the reference standard. Animal studies, laboratory-based studies, reviews and clinical studies not using a reference standard were excluded. Risk of bias (RoB) assessment was performed using a modified Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The random effects model was used for quantitative analysis of the data, and the Deeks test was used for calculating publication bias. Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Twelve articles were included in the systematic review, out of which ten articles were quantitatively assessed. All the articles had a high RoB and concerns regarding applicability in the patient selection domain. For the index test domain, seven articles had low and the remaining five had unclear RoB and concerns regarding applicability. In the reference standard domain, low RoB and concerns regarding applicability were observed for all the articles. The RoB was low in flow and timing domains in all the articles except for one, where it was high. Summary estimates of sensitivity and specificity of US to diagnose periapical granulomas were 0.94 and 0.98, whereas for periapical cysts it was 0.98 and 0.99, respectively. Area under the curve for diagnosis of both periapical granulomas and periapical cysts was 0.99. All the included articles had inherent publication bias. Quality of evidence using GRADE, for sensitivity, was moderate for periapical granulomas and high for periapical cysts, whereas for specificity, it was high for periapical granulomas and low for periapical cysts. DISCUSSION: The available evidence is considered to be of low quality due to the observational nature of the studies and inherent publication bias. CONCLUSION: Although the sensitivity and specificity for differentiating periapical cysts and periapical granulomas using US were high, taking the quality of evidence into consideration, it can serve as an additional tool in differential diagnosis of periapical lesions.

Recombinant Wolbachia surface protein (WSP)-induced T cell responses in Wuchereria bancrofti infections.

Human lymphatic filariasis is a debilitating parasitic disease characterized by downregulation of the host's immune response in asymptomatic carriers along with profound hyperreactivity in chronic patients apart from putatively immune endemic normals. The endosymbiont Wolbachia, a bacterium of filarial nematodes has received much attention as possible chemotherapeutic target and its involvement in disease pathogenesis. The role of recombinant Wolbachia surface protein (rWSP), one of the most abundantly expressed proteins of the endosymbiont, in modulating cell-mediated immune responses in patients harboring Wuchereria bancrofti infections was evaluated in the current study. rWSP-induced lymphoproliferation with peripheral blood mononuclear cells suggested an impaired proliferative response in asymptomatic microfilaremic (MF) and symptomatic chronic pathology (CP) patients compared to endemic normals (EN). This was further supported by a significantly diminished expression of CD69 along with elevated levels of CD127 and CD62L in filarial patients (MF and CP) compared to EN. Further, rWSP induced the expression of regulatory T cell markers CTLA-4 and CD25 along with suppressor cytokines IL-10 and TGF-ß in MF and CP patients compared to EN. However, the rWSP-stimulated expression of IFN-γ was diminished significantly in filarial patients compared to endemic normals. Thus, these findings suggest that WSP may also contribute to the suppression of immune responses seen in filarial patients.

Susceptibility-Weighted MRI as an Imaging Marker for Reperfusion Injury in Acute Ischemic Stroke Following Mechanical Thrombectomy.

Background/Purpose: Following endovascular intervention for stroke, hyperattenuated areas are common in brain parenchyma and it is difficult to differentiate on non-contrast CT whether it is contrast staining or reperfusion hemorrhage. Differentiation between contrast staining from reperfusion hemorrhage is of paramount importance for early initiation of antiplatelets and/or anticoagulants to prevent reocclusion of vessel. This study demonstrates signal characteristics of contrast-staining and reperfusion hemorrhage on susceptibility weighted MRI and its role to differentiate between two. Materials/Methods: Between July 2017 to March 2019, 36 patients who presented with acute ischemic stroke due to large vessel occlusion underwent mechanical thrombectomy. Low-osmolar non-ionic (Iopromide 300 mg/L) iodinated contrast was used in all patients who underwent endovascular intervention. All patients underwent noncontrast CT brain and SWI on 3T MRI within 30 minutes of endovascular intervention. MRI was evaluated by two neuroradiologists. Reperfusion hemorrhage was defined as ECASS criteria II. Symptomatic ICH was defined as hemorrhagic transformation temporally related to a negative shift in NIHSS score >/=4. Results: Out of 36 patients, 15 had hyperattenuated areas in brain on NCCT. Out of 15, 13 patients had blooming on SWI, suggestive of bleed. Two patients had no blooming on SWI, suggestive of contrast staining. Two patients didnot show any hyperdensity on NCCT but blooming on SWI, suggestive of bleed. Conclusion: All patients with hyperdensity on NCCT secondary to bleed showed blooming on SWI whereas those with contrast staining didnot show any signal changes on SWI. Thus, it is possible to differentiate reperfusion hemorrhage from contrast staining using SWI MRI. The significance of SWI in normal CT may be low where a small bleed maynot have any clinical significance.

Immune responses to recombinant Brugia malayi pepsin inhibitor homolog (Bm-33) in patients with human lymphatic filariaisis.

Immune responses to recombinant Brugia malayi pepsin inhibitor homolog (rBm-33) were investigated in patients with human lymphatic filariasis (microfilaremics (MF) and chronic pathology (CP)) along with endemic normals (EN). Flow cytometric analysis (24 h) revealed CD4(+) T cell activation in patients (MF and CP) compared to normals (EN), with increased expression of CD69 and diminished levels of CD62L and CD127. This was associated with an elevated expression of CD154 but not CD28 and CTLA4 in CP patients. However, Bm-33-induced cytokine expression profile (IL-1ß, IL-12, IL-8, IFN-γ, IL-10 and TGF-ß) did not exhibit any significant difference between normals and patients at the same time point. Although CD4(+) T cell activation was observed initially in filarial patients (24 h), lymphoproliferation studies (96 h) suggested diminished proliferation compared to normals, indicating functional inactivation in the former upon prolonged antigen exposure. This indicates that rBm-33 induces an early T cell activation in MF and CP patients followed by a decreased lymphoproliferation that might contribute to immune suppression in these individuals.

Catastrophic Coronavirus Disease COVID Infection Leading to Gangrene of Foot in Peripartum Women.

Introduction: Pregnancy is a physiologically hypercoagulable state and a coronavirus disease 2019 (COVID-19) infection adds to this burden by accentuating the coagulopathy. We report two cases of severe peri-partum COVID infection leading to extremity gangrene secondary to a pro-thrombotic coagulopathy. Case One: A 37-year-old lady, day-2 postpartum, was brought with severe COVID infection & and respiratory failure. She developed progressive gangrene of the foot. A computed tomography (CT) angiogram confirmed the presence of thrombosis of the left external iliac & and common femoral artery. She was managed with catheter- directed thrombolysis and fasciotomy. The dry gangrene of the foot was managed with a Boyd's amputation. At 1-year follow-up, she is ambulant with a healthy stump. Case Two: A 34-year-old lady, 36 weeks of gestation, presented with fulminant COVID infection with respiratory failure and pulmonary embolus. The lady developed gangrene of the B/L toes. A CT angiogram revealed thrombosis below the popliteal trifurcation in both limbs along with segmental pulmonary thrombo-embolism involving the right lung and multiple splenic infarcts. She succumbed to the overwhelming infection and sepsis. Discussion: The pathogenesis of coagulopathy in pregnant COVID patients is attributed to the hypercoagulable effect, which leads to thrombo-embolisms and limb ischemia following a cytokine storm syndrome in severe infections. To date, this is the first experience detailing distal limb gangrene in fulminant COVID infection in peri-partum women. Although, cases have been reported on distal limb gangrene in severe COVID infection among non-pregnant individuals. Conclusion: A multidisciplinary team must manage COVID infections in the third trimester. A prompt recognition of any forms of lethal coagulopathy and vigilant treatment will prevent loss of life.

Wuchereria bancrofti: diminished platelet activation in filarial patients.

Blood platelets are the innate immune elements that have not been investigated in human filarial infections. Platelet activation status in the endemic normals (EN), microfilaria positive individuals (MF) and patients with chronic pathology (CP) was evaluated in whole blood, under unstimulated as well as antigen exposed (BmA, E. coli) conditions for PAC-1 expression by Flow cytometry. A diminished PAC-1 expression was observed in MF compared to CP and EN spontaneously as well as upon antigen exposure. Besides this, PAC-1 expression within the groups did not exhibit any significant difference under all the experimental conditions. However in CP patients, E. coli antigen exposure resulted in a significantly reduced PAC-1 expression compared to the spontaneous expression levels. NO release in platelet culture supernatants from EN was inversely proportional to platelet aggregation. Collagen stimulated platelets from EN, exposed to sera and immune complexes from CP and MF patients resulted in elevated Nitric Oxide (NO) release, compared to those exposed to autologous sera and fetal calf serum. In addition, under similar conditions, collagen stimulated platelets from EN, exposed to filarial antigen (BmA) exhibited increased NO compared to the E. coli antigen exposed ones and light microscopic observations of cultured platelets supported the above findings. Thus it appears from the results of the present study that filarial antigen may play a role in the loss of platelet aggregation, leading to platelet inactivation.

A study on the resting preference of mosquito species in wells in Vellore in Tamilnadu, South India.

The resting preferences of mosquito species was investigated in domestic wells. In addition to the routine adult surveys in human dwellings, adult collections were also made in domestic wells using an innovated equipment operating on the principles of spray sheet collections. Above the water surface, wells provide humid and dark microclimate along the inner walls. It has been observed that this microclimate provides very congenial resting place for few mosquito species; specially for the males and for the females between their gonotropic cycles. Larval collections in the wells did not reveal breeding of majority of the mosquito species collected by this technique. Investigations were conducted in 87 wells in 11 localities during 2005. A total of 4969 mosquitos were collected of which 69.1% (3441) were males and 30.9% (1528) were females. From among the mosquitos collected 96.5% were Cu. quinquifasciatus, 0.26% All stephensi, 3.0% Aedes agypti and 0.24% Armegeres sp. The results of the analysis of the physical and chemical parameter of water samples of the study wells before and after the surveys endorsed the utility of this technique for entomological investigations in outbreak situations, for monitoring the liquidation of outbreak foci and for other research purposes.

Two Cases of Lingual Arteriovenous Malformations with Comorbidities Treated by Glue Embolization: A Report with Review of Literature.

Arteriovenous malformations (AVMs) involving the tongue are uncommon lesions in the head and neck region. They present with bleeding that can be massive and life-threatening apart from debilitating symptoms of pain, ulcers, difficulty in phonation or swallowing. Various therapeutic approaches have been used in their management-surgery, endovascular embolization, radiation and ablation procedures like laser ablation. We report two patients-a 34 year-old man and 56 year-old female who presented with massive bleeding due to lingual AVM and had comorbidities as liver cirrhosis and chronic medical renal disease respectively, and treated with glue embolization, with a review of the literature.

Portfolio as a learning tool: students' perspective.

Portfolio writing is a method of encouraging reflective learning among professionals. Although portfolio-based learning is popular among educators, not many studies have been done to determine students' perceptions of portfolio as a learning tool. A questionnaire survey was conducted among 143 medical students to find out their perceptions of the portfolio as a learning tool. A majority of the students felt that the portfolio is a good learning tool. However, they also perceived that it is stressful and time-consuming to develop a proper portfolio. The study indicates that students need appropriate guidance from the academic staff for the system to succeed.

Recent trends in the diagnosis and management of allergic rhinitis.

Allergic rhinitis is a global health issue and its prevalence is increasing. Allergic rhinitis and asthma coexist in many patients. Allergic rhinitis is an Ig E mediated reaction. Prostaglandins and Leukotriens do not play a significant role in the pathogenesis of allergic rhinitis. Skin prick test and Enzyme linked immunosorbent assays (ELISA) are useful as diagnostic tests. The three major modalities of treatment for allergic rhinitis are allergen avoidance, pharmacotherapy and immunotherapy.

Hearing impairment in the elderly.

Hearing impairment is one of the most important health problems of the elderly above 60. Very often it leads to verbal communication difficulty and without treatment it can cause serious psychological and social complications such as depression and social isolation. Prebyscusis remains a leading cause of sensorineural deafness in the elderly. Elderly patient must be encouraged to seek proper hearing assessment if they face hearing difficulty. Active screening by health care workers and patient self-evaluation by answering a simple list of screening questions are possible for early detection and treatment of hearing loss in the elderly. Although hearing loss in the elderly may not have a cure, early rehabilitation helps to restore better quality of life if the problem is detected early.

Aetiology of deafness in children from a school for the deaf in Malaysia.

One hundred and sixty-five children from the school for the deaf were screened to find out the aetiology of deafness. The screening included routine ophthalmological examination. Aetiology was unknown in 33 children (20%). Prenatal infection was found to be the cause of deafness in 61 cases (36.96%). Rubella eye signs were found in 59 children (35.76%), whereas the history of rubella infection during the first trimester of pregnancy was found in only 33 of these cases (55.93%). Perinatal complications were seen in 20 children (12.12%). Twenty children (12.12%) had meningitis during their early childhood period. Routine ophthalmological examination helped us to pick up cases with rubella eye signs. Ophthalmological examination should be included as part of any study done to find out the cause of deafness.

Childhood deafness in Malaysia.

One hundred and fifty-five children with childhood deafness were examined over a period of 4 years in order to assess the aetiology of hearing disorder. In 21 (13%) children, deafness was a sequel of meningitis. Perinatal pathology accounted for 34 (22%) cases. The aetiology of deafness was unknown in 44 (28.4%) children. The percentage of unknown causes can be reduced if the deafness is detected early. Hearing loss was diagnosed only in 30 (19%) children by the age of 2 years. The early detection of deafness can be achieved by screening the high risk infants and educating the general practitioners and health assistants.

Additional conductive hearing loss in children from a school for the deaf in Malaysia.

A total of 165 children from a school for the deaf in Malaysia were screened to find out the prevalence of additional conductive hearing loss. Otological examination, tympanometry and pure tone audiometry were performed in all these children. Fifty-one children (30.9%) had additional conductive hearing loss. Middle ear disorders were present in 15 children (9.09%). The deaf children seldom complain about the change in their hearing sensitivity, so there is a need for regular otological examination in deaf children to detect the additional conductive hearing loss.

Hearing loss and ear disorders in Malaysian school children.

In Malaysia 1,307 randomly selected primary school children were screened to find out the prevalence of hearing loss and middle ear disorders. Seventy-six students (5.81%) failed the screening audiometric test. There were 95 students (7.26%) with middle ear disorders. History of ear discharge was absent in 24 out of 57 cases with CSOM (42.11%) (P less than 0.001). Forty-three out of 95 children having middle ear disorders passed the screening audiometric test (P less than 0.01 Fisher exact test). Screening audiometric test fails to detect about 46% of cases with middle ear disorders. Screening audiometric test and otological examination if conducted by the school health medical officers regularly will be able to detect almost all the cases with hearing loss and middle ear disorders.

Parapharyngeal space melioidosis in a diabetic.

Pseudomonas pseudomallei, a gram negative organism causing melioidosis, is found in tropical and subtropical regions. It may manifest as a pulmonary lesion, osteomyelitis, soft tissue abscesses, abscesses in various organs or in septicaemic form. Melioidosis of the parapharyngeal space has not been reported so far. A case of melioidosis of the parapharyngeal space which was successfully treated by drainage and prolonged antibiotic therapy is reported here. Melioidosis should be suspected in severe forms of deep neck space infection, especially if the patient comes from an endemic area.

Nasopharyngeal carcinoma with secondaries at the porta hepatis presenting as obstructive jaundice.

Recent reports have dispelled the previously held concept that head and neck cancer rarely metastases beyond the cervical lymph nodes. Nasopharyngeal cancer has been reported to have a higher incidence of distant metastases compared to other head and neck cancers, the common sites being bone, lung and liver. A case of nasopharyngeal carcinoma presenting as obstructive jaundice because of secondaries at the porta hepatis is presented here.

Nasopharyngeal carcinoma with spinal secondaries.

Nasopharyngeal carcinoma has been reported to have a higher incidence of distant metastases as compared to other head and neck cancers. Distant metastases of nasopharyngeal carcinoma has been reported in the bones, lungs, liver, distant lymph nodes, brain and porta hepatis. This report presents a case of nasopharyngeal carcinoma with secondaries in the extradural space at the thoracic level of the spinal cord which hitherto has been an unreported site.

Orbital complications of acute sinusitis.

Orbital complications of sinusitis may occur either by spread along the venous system or by direct extension of infection between contiguous structures. The association between sinusitis and inflammation of the orbits has been known for centuries. But in the post antibiotic era there is a marked decline in the number of case reports in the literature. This paper presents 10 cases of sinusitis who had orbital complications. The classification of this disease complex as given by Chandler helps in planning the treatment. Groups I and II respond very well to antibiotics but in groups III, IV, V surgical intervention is necessary. Early identification and aggressive therapy reduces the morbidity of this disease.