A Genetic Locus in Elizabethkingia anophelis Associated with Elevated Vancomycin Resistance and Multiple Antibiotic Reduced Susceptibility.

The Gram-negative Elizabethkingia express multiple antibiotic resistance and cause severe opportunistic infections. Vancomycin is commonly used to treat Gram-positive infections and has also been used to treat Elizabethkingia infections, even though Gram-negative organisms possess a vancomycin permeability barrier. Elizabethkingia anophelis appeared relatively vancomycin-susceptible and challenge with this drug led to morphological changes indicating cell lysis. In stark contrast, vancomycin growth challenge revealed that E. anophelis populations refractory to vancomycin emerged. In addition, E. anophelis vancomycin-selected mutants arose at high frequencies and demonstrated elevated vancomycin resistance and reduced susceptibility to other antimicrobials. All mutants possessed a SNP in a gene (vsr1 = vancomycin-susceptibility regulator 1) encoding a PadR family transcriptional regulator located in the putative operon vsr1-ORF551, which is conserved in other Elizabethkingia spp as well. This is the first report linking a padR homologue (vsr1) to antimicrobial resistance in a Gram-negative organism. We provide evidence to support that vsr1 acts as a negative regulator of vsr1-ORF551 and that vsr1-ORF551 upregulation is observed in vancomycin-selected mutants. Vancomycin-selected mutants also demonstrated reduced cell length indicating that cell wall synthesis is affected. ORF551 is a membrane-spanning protein with a small phage shock protein conserved domain. We hypothesize that since vancomycin-resistance is a function of membrane permeability in Gram-negative organisms, it is likely that the antimicrobial resistance mechanism in the vancomycin-selected mutants involves altered drug permeability.

A rare case of Guillain-Barrè syndrome with unilateral facial palsy and asymmetrical ascending weakness: a case report.

Guillain-Barrè syndrome is a life threatening postinfectious disease causing acute paralytic neuropathy that rarely presents with asymmetrical limb weakness (1%) and unilateral facial nerve palsy (4.9%). Case Presentation: A 39-year-old male presented with pain and weakness in the right lower limb with right sided facial weakness. The cranial nerve examination revealed lower motor neuron type right facial palsy (Bell 's palsy). On rest neurological examination, he had decreased power in the right lower limb with an absent knee and ankle reflex on presentation. Later, the weakness was symmetrical in both lower limbs. Clinical Discussion: Cerebrospinal fluid analysis showed albuminocytologic dissociation with no cells and an elevated protein of 203.2 mg/dl. The nerve conduction study was abnormal in bilateral lower limbs suggesting severe demyelinating motor neuropathy. Intravenous Immunoglobulin was started with the dose of 25 gm (0.4 mg/kg) once daily for 5 days, that is, five doses. The patient started showing signs of recovery with the initial dose of immunoglobulin. Conclusion: The course of the disease usually recovers spontaneously and completely; however, plasma exchange and immunomodulatory therapy have shown improvement in patient with rapidly deteriorating symptoms.

Primary thyroid tuberculosis mimicking papillary carcinoma of thyroid: a rare case report.

Primary thyroid tuberculosis is an extremely rare extrapulmonary involvement by the causative agent, Mycobacterium tuberculosis. Its rarity and resemblance to thyroid malignancy led to unnecessary aggressive operative interventions. Case Presentation: A 54-year-old female presented with recent onset dysphagia and foreign body sensation in the throat for 3 months, and anterior neck swelling since last 10 years. Clinical Findings and Investigations: A single nodular firm anterior neck swelling was present which moves with deglutition. Thyroid function test was normal. Ultrasonography thyroid revealed TIRADS-3. Fine-needle aspiration cytology was suggestive of papillary carcinoma of thyroid. Interventions and Outcome: Total thyroidectomy with central compartment neck dissection was performed. Histopathology of the thyroid specimen revealed tubercular thyroiditis. Postoperatively, Mantoux test and interferon gamma radioassay were positive. Antitubercular therapy was given for total of 6 months. Conclusions: With ultrasonography-guided fine-needle aspiration cytology, preoperative diagnosis of primary thyroid tuberculosis is quite challenging even in tuberculosis endemic countries. So, it should be considered one of the differential diagnoses despite negative relevant history and without clinical cervical lymph nodes involvement with cytology proven suspicious papillary thyroid cancer before proceeding for surgical intervention.

Small bowel intussusception in an adult secondary to gastrointestinal stromal tumor: a rare case report.

Intussusception is a rare surgical condition in adults less commonly confined to small bowel. Adult intussusception is an indication of surgical resection due to possibility of ischemia and malignant pathological cause like gastrointestinal stromal tumor (GIST) as in this case. Case presentation: A 32-year-old male presented with abdominal pain and vomiting for 3 days. Vitals parameters and abdominal examinations were normal. Abdominal ultrasonography revealed target sign suggesting ileoileal intussusception in right lower quadrant. Abdominal contrast-enhanced computed tomography of abdomen showed features suggestive of ileoileal intussusception. Diagnostic laparoscopy was done which was later turned to laparotomy for segmental resection and anastomosis of ileum for ileoileal intussusception. Polypoidal growth noted in the resected section of ileum was found to be GIST (CD117 and DOG-1 positive) which was considered to be the lead point. Patient recovered well during postoperative period and later referred to oncology clinic for chemotherapy. Clinical discussion: Intussusception and subsequent obstruction are very uncommon presentation in a patient with GIST because of their tendency to grow in an extraluminal fashion. As intussusception is rare in adult, high level of suspicion and proper imaging technique plays important role in diagnosing the condition. Conclusion: Ileoileal intussusceptions due to GIST are a rare clinical entity in adult intussusceptions and generally have a vague variable clinical presentation thus requiring high index of clinical judgement and suspicion with judicious use of imaging.

A rare case of intramuscular hemangioma of splenius capitis: a case report.

Intramuscular hemangiomas are benign lesion that rarely occurs within the skeletal muscle of the head and neck regions. These lesions present with nonspecific symptoms resulting in only a few instances of accurate preoperative diagnosis. Case Presentation: A 20-year-old male presented with swelling over the nape of the neck on the right side. On clinical examination, the solitary swelling was 4×4 cm on measurement, soft on consistency with regular margin, fluctuant, with no skin changes over the swelling, nontender, no restriction in range of motion of the neck, and no pulsation felt. Clinical Findings and Investigations: Ultrasonography and contrast-enhanced MRI revealed intramuscular hemangioma involving the right splenius capitis muscle with no extension to adjacent muscles and minimal extension to the subcutaneous tissue. Interventions and Outcome: Excision of the lesion along with splenius capitis was performed with stable postoperative hemodynamics. Conclusion: Since intramuscular hemangiomas pose a challenge in preoperative diagnosis, it requires the sensible use of imaging modalities. Although several treatment modalities have surfaced, intramuscular hemangiomas require definitive operative management to reduce their recurrence.

Pubertal extravaginal nontraumatic spontaneous testicular torsion: a case report.

Testicular torsion (TT) is the most common urosurgical emergency in the case of acute scrotal pain. Early diagnosis, both clinically with imaging and emergent surgical exploration, is the key step in the salvage of testis and its management. Case Presentation: A 12-year-old male with no known comorbidities came to the emergency department of our center with complaints of left scrotal region pain and swelling for 10 h. Clinical Findings and Investigation: Left testicular tenderness and swelling with Phren's sign negative, Deming's sign positive, and absent cremasteric reflex. Ultrasonography showed coarse echotexture with a lack of obvious vascularity in the left testicle suggestive of TT and bulky left epididymis with bilateral hydrocele; left side greater than right. Intervention and Outcome: The patient underwent emergency left orchidectomy with right orchidopexy. Following this, he was symptomatically better, and the excruciating testicular pain and swelling subsided. Conclusion: Extravaginal TT is a rare presentation in pubertal age groups; however, whatever may be the types and causes, TT is a urological emergency that may lead to permanent ischemic necrosis. Delays in diagnosis should be avoided as this is directly related to the percentage of testicular salvage or loss. Prompt emergent surgical exploration is the cardinal point in management.

Evisceration of intestines with diaphragmatic laceration and gastric perforation secondary to trauma by rhinoceros attack and its management: a case report.

Injuries from animal attack are one of the major public health problems at present scenario globally. Proper documentation is required for the study of different types of injuries caused by animal attacks so that early intervention can be done during life-threatening conditions. Case Presentation: A 36-year-old male presented with an alleged history of attack by two rhinoceros sustaining injuries over the abdomen, chest, shoulder and thigh. Clinical Findings and Investigations: There was a lacerated abdomen with evisceration of the stomach, small intestine, transverse colon and omentum and a lacerated wound over the left lateral thigh and left buttock along with the right shoulder. Extended Focused Assessment with Sonography in Trauma ultrasound showed minimal free fluid in the pelvis. Blood profile revealed reduced haemoglobin and deranged prothrombin time/international normalized ratio. Interventions and Outcome: Patient underwent exploratory laparotomy twice with repair of diaphragmatic injury, excision of avulsed greater omentum in the first setting and repair of gastric perforation in the second setting with stable haemodynamic status. Conclusion: Abdominal evisceration injury by rhinoceros attack is life threatening though rare. Its management should consist of assessing for and controlling associated haemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents and early reduction of viscera if there is no active bleeding.

Transaminitis among Patients with Dengue Fever Visiting a Tertiary Care Centre.

Introduction: Transaminitis is a condition where serum aspartate transaminase and alanine transaminase increase indicating liver dysfunction. One such disease where liver involvement might be observed is dengue, which is a mosquito-borne viral infection. The aim of the study was to find out the prevalence of transaminitis among patients with dengue fever in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted in a tertiary care centre from 1 November 2022 to 31 March 2023 after obtaining ethical approval from the Institutional Review Committee. Informed written consent was taken before collecting the data. A rapid immunochromatography test was used to confirm dengue infection. Serum aspartate transaminase and alanine transaminase were measured through routine Reitman and Frankel's enzymatic method. Dengue-confirmed patients from the medical outpatient department, fever clinic, and medical ward of the centre were included in the study. Patients with known prior liver diseases or any other chronic diseases, pregnancy, and patients in the hospice unit were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 442 dengue infected patients, the prevalence of transaminitis was 188 (42.53%) (37.92-47.13, 95% Confidence Interval). The highest frequency of dengue positive was observed among the 18-35 years age group, which was 97 (51.59%) with male predominance 134 (71.27%). Conclusions: The prevalence of transaminitis among patients with dengue fever in a tertiary care centre was found to be lower than other studies done in similar settings. Keywords: alanine transaminase; aspartate transaminase; dengue.

Spontaneous rupture of renal angiomyolipoma and its management: A case report.

a Introduction and Importance: Angiomyolipomas of kidney are benign lesions that are generally an incidental finding on imaging. Rupture of angiomyolipoma is rare and fatal complication that requires early intervention. b Case Presentation: A 38 year old male patient presented with symptoms of right flank pain for 2 days. On clinical examination patient looked anxious, pale with right flank tenderness, guarding and signs of shock. c Clinical findings and investigations: CT scan showed renal angiomyolipoma with aneurysm formation and bleed from the lesion. Blood profile revealed low hemoglobin. d Interventions and Outcome: Right nephrectomy performed along 6 cycles of cardiopulmonary reususcitaion done with stable post operatively vitals. e Conclusion: Early diagnosis of complication of angiomyolipoma requires thorough clinical examination and judicious use of imaging. Immediate embolization or surgery must be performed for better outcome and survival rate.