Scrub typhus meningoencephalitis presenting as opsoclonus myoclonus syndrome: A video-based case.

Opsoclonus myoclonus syndrome secondary to scrub typhus infection is a rare clinical entity. Hence, it is important to know its clinical manifestations and complications, so that it can be properly managed. We report a 28-year-old female whose initial manifestation was only fever, which subsided in four days. Two days later, she developed opsoclonus myoclonus syndrome. This was managed with doxycycline and clonazepam, but as it persisted, intravenous immunoglobulin was added. She showed excellent response to treatment.

Linezolid-Associated Posterior Reversible Leuco-encephalopathy Syndrome in a Patient with Disseminated Tuberculosis.

Neurological side-effects of linezolid manifesting as a posterior reversible leuco-encephalopathy syndrome (PRES) is rare. Early identification of this offending drug might reverse this catastrophic event. We report a 45-year-old female, who was diagnosed as a case of disseminated tuberculosis and was treated with antitubercular drugs (ATT), but later developed ATT-induced hepatitis. She was then put on modified ATT (moxifloxacin, terizidone, and linezolid). In the next two days she developed an altered sensorium. Brain imaging was suggestive of PRES. Linezolid was withdrawn, following which she showed an excellent clinical and radiological recovery.

An Unusual Case of Muscle Twitching: Its LGI1.

A 50-year-old male, presented with a two-months history of ascending paresthesias, with continuous twitchings over the body, associated with insomnia. His electromyography (EMG) revealed neuromyotonia and was diagnosed as a case of peripheral nerve hyperexcitability (PNH) syndrome due to Leucin-rich glioma-inactivated 1 (LGI1) antibody. He showed significant improvement with intravenous immunoglobulin and carbamazepine.

Urinary Calculi: A Microbiological and Biochemical Analysis at a Tertiary Care Hospital in Eastern Nepal.

BACKGROUND: The occurrence of urinary tract infection in presence of urolithiasis is frequently noted; however, microbial agents of urolithiasis and their antimicrobial susceptibility patterns remain underinvestigated. This study aimed to identify the microorganisms isolated from urine and stone matrices to determine their antimicrobial susceptibility, to find the association between the pathogens of urine and stone matrices, and to perform the biochemical analysis of stones. METHODS: A total of 88 cases of urolithiasis admitted for elective stone removal at Department of surgery, B.P. Koirala Institute of Health Sciences (BPKIHS), were enrolled. Preoperative urine culture and postoperative stone culture were performed. Isolation, identification, and AST were done by the standard microbiological technique. Further qualitative biochemical analysis of stones was also attempted. RESULT: Among 88 stone formers recruited, culture of urine, whole stone, and nidus yielded the growth of bacteria 44, 32, and 30, respectively. Bacteria isolated from urine culture correlated with those from stone matrices with a sensitivity of 90%, specificity of 79.69%, PPV of 63.64%, and NPV of 95.45%. Escherichia coli (46.7%) was the most common bacteria followed by Klebsiella pneumoniae (16.7%) and Proteus mirabilis (13.3%) from urine and stone cultures. Almost all the uropathogens isolated were susceptible to commonly used antibiotics. Calcium oxalate (84.1%) was common biochemical constituent found in stone formers followed by calcium oxalate + phosphate (8%). CONCLUSIONS: The association of microorganism isolated from urine and nidus culture was significant that can predict the source of infective stone; however, in some cases, microorganisms and the antimicrobial susceptibility pattern from urine and nidus were different. This study emphasizes the use of appropriate antimicrobial agents to prevent the regrowth of residual stones and minimize the risk of infectious complications after surgical removal of stones.

Aspirin and Clopidogrel Resistance in Indian Patients with Ischemic Stroke and its Associations with Gene Polymorphisms: A Pilot Study.

INTRODUCTION: Antiplatelet resistance is one of the urgent issues in current stroke care. One-third to one-half of the patients who experience a recurrent stroke is already on antiplatelet medications. We studied resistance to aspirin and clopidogrel in Indian stroke patients and its association with gene polymorphisms. METHODS: Platelet function testing by light transmission aggregometry was performed on 65 patients with ischemic stroke who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 75 mg OD) along with 65 age-matched controls. Aspirin resistance was considered as mean platelet aggregation ≥70% with 10 µM adenosine diphosphate (ADP) and ≥20% with 0.75 mM arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 µM and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19 * 2 and GPIIb/IIIa (PLA1/A2) were genotyped by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: We found 64.6% (42/65) patients with inadequate response to clopidogrel (15.4% [10/65] resistant and 49.2% [32/65] semi-responders) and 4.6% (3/65) patients with inadequate response to aspirin (3.1% [2/65] resistant and 1.5% [1/65] semi-responder). The frequency of CYP2C19*2 mutant genotype was significantly higher in clopidogrel nonresponders compared to responders (P = 0.014). Clopidogrel nonresponsiveness was much higher in small vessel stroke. CONCLUSION: Unlike aspirin, a high proportion of nonresponders to clopidogrel was identified. In an interim analysis on 65 Indian patients, a significant association was found between CYP2C19*2 and clopidogrel nonresponsiveness.

Laparoscopic Choledochotomy in a Solitary Common Duct Stone: A Prospective Study.

BACKGROUND: Laparoscopic common bile duct exploration has all the advantages of minimal access and is also the most cost effective compared to the other options. OBJECTIVE: To study a profile on laparoscopic common bile duct exploration for a single common duct stone. METHODS: A total of 30 consecutive patients with solitary common bile duct stone attending our hospital over a period of one year were enrolled in the study. Laparoscopic common bile duct exploration was done by transductal route in all the patients. RESULTS: There were 18 females and 12 males with age ranging from 28 to 75 years. Jaundice was present in 12 (40%) patients. Twenty-four (80%) patients had raised alkaline phosphatase. The mean size of CBD on ultrasound was 11.55 mm. The mean size of calculus was 11.06 mm and was located in the distal CBD in 26 (86.7%) patients. The mean operative time was 158.4 ± 57.89 min. There were 8 (26.6%) conversions to open procedure. T-tube was used in 26 (86.7%) patients. The postoperative complications were hospital acquired chest infection in 3 (10%), surgical site infection in 3 (10%), acute coronary syndrome in one (3.3%), and bile leak after T-tube removal in one (3.3%) patient. CONCLUSIONS: Laparoscopic common bile duct exploration is an effective, safe management of common bile duct stone.

Meningitis with polymerase chain reaction for varicella zoster positivity in cerebrospinal flid of a young immunocompetent adult.

Meningitis caused by varicella zoster virus (VZV) is quite rare among young immunocompetent adults though immunocompromised patients are often seen to be affected by reactivation of VZV presenting with primary clinical features of dermatomal rashes and neurological sequelae. Here, we report the clinical scenario of a young, healthy male who had presented with fever, headache, and onset of dermatomal rashes later than the fever and was eventually diagnosed to be a case of VZV meningitis. We would like to highlight the fact that even young immunocompetent patients though rarely, might contract VZV meningitis and clinicians should have a high index of suspicion and keen eyes to catch the more obvious features of VZV infection on complete physical examination and must not harbor any reservations in ordering polymerase chain reaction for VZV DNA or initiating aggressive antiviral therapy.

Bile duct injuries during open and laparoscopic cholecystectomy: management and outcome.

BACKGROUND: The widespread application of laparoscopic cholecystectomy has led to a rise in the numbers of major bile duct injuries (BDI). Perioperative management of these injuries is complex and challenging. There are few published reports locally regarding the perioperative management of BDI. Purpose of this review was to analyze our experience in diagnosis, management and prevention of BDI. METHODS: This study was conducted in department of surgery at B. P. Koirala Institute of Health Sciences. From January 2001 to September 2010, a observational study of all patients with a BDI following cholecystectomy was maintained. Patients' charts were retrospectively reviewed to analyze incidence, type of injury, presentation, and perioperative management of BDI. RESULTS: A total of 92 patients had BDI which occurred during cholecystectomy, were analysed retrospectively. There were 60/92 (65.5%) patients with BDI resulting from the wrong identification of the anatomy of the Calot's triangle during cholecystectomy. Abdominal ultrasonography was diagnostic for BDI in 71/90 (78.8%). Magnetic resonance cholangiography could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 22/23 (95.6%). The most common injury was Strasberg's E2 in 65/92 (70.7%). A transection or stricture of the bile duct was repaired by hepaticojejunostomy (83 cases in this series). Seventy-five (81.5%) patients were followed up. The mean follow-up time was 2.6 years (range 0.16-6). Good results were achieved in 62/75 (82.6%) of the patients. CONCLUSIONS: The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Examination of relationship of scores obtained in grades 10 and 12 with the entry and success in undergraduate medical education.

BACKGROUND: Entrance examination (admission test) is the most important and widely accepted method of student selection for admission into medical schools in Nepal. For many schools it is the only criterion of student selection. OBJECTIVES: To examine relationships of scores obtained in schooling (grade 10 and 12), medical entrance and MBBS professional examinations in a cohort to identify predictive strength for entry into medical school and success in medical education. METHODS: Exam scores from grade 10 to medical entrance and professional exams of undergraduate medical education of a total of 118 medical students who entered medical school between 1994 and 1998 only through the merit of open competitive medical entrance examination at the BP Koirala Institute of Health Sciences (BPKIHS) were assessed. RESULTS: Student selection for admission in MBBS course at BPKIHS and their subsequent success were not determined by difference in outcomes of public and private management of schools at grade 10 (selection p= 0.80 and success p= 0.32 ) and grade 12 (selection p= 0.59 and success p= 0.55). Grade 12 averaged scores had no relationship in getting these students selected for admission into medical course (r= 0.08, p= 0.37), but did show correlation with the overall success in medical education (r= 0.32, p= 0.00). Scores in physics at grade 12 retained predictive strength in success in medical education (r= 0.19, p= 0.04). CONCLUSION: The present student selection criteria for medical education are not appropriate and need to incorporate other attributes of candidates along with cognitive aspects.

Redo-laparotomies: reasons, morbidity and outcome.

A large number of patients undergo various operative procedures every day and laparotomy forms a large proportion. At times, laparotomies have to be redone due to complications like biliary peritonitis, faecal fistula, burst abdomen or anastomotic leak. Our objectives were to determine the causes of Redo-laparotomy evaluate morbidity associated with it and analyze its outcome. A prospective study of patients in BP Koirala Institute of Health Sciences (BPKIHS) from 1. 1. 2009 to 31. 12. 2009 was done. Institutional ethical clearance was taken. The Statistical analyses were done using SPSS version 11.5. Redo-laparotomy was performed in 40(1.99%) cases. The mean age was 31.99 +/- 21.49 years with a M: F ratio of 4:3. The indications of Redo-laparotomy were: burst abdomen (n = 9; 22.5%), followed by intra-abdominal collection and abscess (n = 7; 17.5%), fecal (n = 6; 15%), and biliary peritonitis (n = 5; 12.5%). The mean duration between first laparotomy and Redo was 9.42 +/- 7.56 days and the mean duration of hospitalization was 26.98 +/- 12.50 days. Lower gastrointestinal surgeries usually lead to a Redo. The mortality in our study was 30% and 21/40 patients had to be managed in the intensive care unit. Clinical acumen formed the basis (87.5%) to decide for Redo-laparotomy in the majority. Redo-laparotomies that are performed following complicated abdominal surgeries have high morbidity and mortality rates. Multiple factors may lead to a Redo-laparotomy which is beyond the hands of a clinician yet a vigilant and vigorous management could help reduce the rate of Redo-laparotomies.

Abdominal cocoon in an adolescent male.

Abdominal cocoon is an uncommon peritoneal condition characterized by partial or complete encasement of small bowel by a thick rind of fibrous tissue and adhesions. Only few cases of this disease have been reported in world literature. The etiology of this condition is unknown, and most often it is found in adolescent girls from tropical or subtropical countries, and usually diagnosed incidentally on exploration. Surgery (membrane dissection and extensive adhesiolysis) is the treatment of choice. Here, we report a case of abdominal cocoon in a 20-year-old male patient, with a brief review of the literature.

Rise in liver enzymes after laproscopic cholecystectomy: a transient phenomenon.

The purpose of this study was to investigate the effect of laparoscopic surgery on liver function in humans and the possible mechanisms behind such effect. Blood samples from 30 patients who underwent laparoscopic cholecystectomy (LC) and 20 patients who underwent open cholecystectomy (OC) were tested for liver function by measuring the level of serum alanine aminotrasferase (ALT) and aspartate aminotrasferase (AST) before and after surgery. The level of serum ALT and AST increased significantly during the first 24 hours after surgery in laparoscopic cholecystectomy. However, no significant change of the serum liver enzymes was detected in open cholecystectomy patients. As a result, there was statistically significant difference in change of both ALT and AST levels between LC and OC patients. The effect was transient and reverted back to normal by the 7th day post operation. Transient elevation of hepatic transaminases occurred after laparoscopic surgery. The major causative factor seemed to be the CO2 pneumoperitoneum. In most of the laparoscopic surgery patients, the transient elevation of serum liver enzymes showed no apparent clinical implications.

Effect of the Alvarado score on the diagnostic accuracy of right iliac fossa pain in an emergency.

Acute appendicitis is among the commonest surgical diseases faced by an emergency clinician. A prompt diagnosis is mandatory to reduce morbidity and mortality, which may be difficult for junior doctors who first see the patient in the emergency department. This study was conducted to assess the efficacy of Alvarado score as a tool to improve the accuracy of diagnosis of appendicitis. We did a prospective pre- and post-test study in 381 patients with right iliac fossa pain in the emergency department of BP Koirala Institute of Health Sciences. Alvarado scoring was used for the post-test study. We found that the Alvarado scoring system is an effective diagnostic method, which decreases overdiagnosis of appendicitis in the emergency department, and at the same time reduces the risk of missing acute appendicitis cases. It is inexpensive and easy to implement by junior doctors with good results.

Transfer of clinical breast examination skills to female community health volunteers in Nepal.

OBJECTIVE: To observe skill transfer for detection of clinical abnormalities in the breast by determining kappa agreement, sensitivity, specificity, positive predictive value and negative predictive value of clinical breast examination by female community health workers (FCHVs) considering surgeon findings as the gold standard. METHOD: This cross-sectional study was conducted in Dharan Municipality, Eastern Nepal for period of one year from June 2008 to May 2009. A total of 1,238 women were examined by both a FCHV and the surgeon. RESULT: The interobserver kappa agreement for the detection of clinical abnormalities in breast was 67% indicating a good agreement. Sensitivity, specificity, positive predictive value and negative predictive values of "FCHVs' clinical breast examination" to detect clinical abnormalities in breast in comparison to the surgeon's were 70%, 95%, 74% and 94% respectively. CONCLUSION: In view of good clinical breast examination skill transfer to FCHVs for detection of clinical abnormalities in breast, we conclude effective training of FCHVs may be a feasble approach for diagnosis of breast abnormalities in rural Nepal.

Rectosigmoid endometriosis causing an acute large bowel obstruction: a report of a case and a review of the literature.

Endometriosis is often seen in gynecology practice and is treated medically. However, intestinal involvement of endometriosis causing acute large bowel obstruction is uncommon and is difficult to differentiate from malignancy before surgery, owing to its similar colonoscopic and radiologic findings. We report a successfully-treated case of a 30-year-old woman in which endometrial infiltration of the large bowel caused acute obstruction, requiring emergency surgery to relieve the symptom and confirm the diagnosis. We present this unusual disease in general surgical practice and also review the literature.

Conservative treatment in acute appendicitis.

INTRODUCTION: Acute appendicitis is one of the commonest surgical problems and appendectomy is one of the most commonly done operations in the emergency world wide. Though there have been occasional reports with conservative treatment in acute appendicitis, it is not being practiced as a routine. METHODS: All patients between ten to sixty years of age admitted at BPKIHS with the diagnosis of acute appendicitis over a period of one year were enrolled in the study. After taking informed consent the patients were managed conservatively. Those who did not respond to antibiotics within 24 hours were operated. Total hospital stay and complications were recorded and they were followed up at first week, sixth week and sixth month. The success rate, conversion rate, recurrence rate and morbidity and mortality pattern were assessed as the final outcome of conservative treatment of acute appendicitis. RESULTS: A total of 96 patients (48 males and 48 females) underwent conservative treatment. The conservative treatment was successful in 79 (82.3%) cases and failed in 11 (11.4%) cases, which included: conversion to appendectomy during conservative treatment period 4 (4.2%) cases, recurrence 7 (7.3%) cases. There was no mortality in this study. CONCLUSION: Acute appendicitis can be treated successfully with conservative (antibiotics) treatment with a short hospital stay. Though there is a risk of recurrence in some cases, all the complications after appendectomy can be eliminated with the conservative treatment.

Multiple skeletal metastases as unusual manifestations of hepatocellular carcinoma in a noncirrhotic liver.

Hepatocellular carcinoma is the most frequent primary malignant tumor of the liver. Bony metastases of hepatocellular carcinoma are usually rare, in which most common sites involved are vertebra and pelvis. Still rarer are metastases to the chest wall and skull. We report a case of a 45-year old man with unusual metastases of hepatocellular carcinoma to skull, sternum and ribs. These combinations of metastases have rarely been reported in literature.