Chyluria in a Postpartum Obese Female Patient.

Chyluria characterized by the passage of milky white urine is rarely encountered these days due to the overall reduction in the number of cases of lymphatic filariasis. Though lymphatic filariasis accounts for the majority of cases of chyluria, nonparasitic causes have also been reported. Case reports of chyluria as a complication in pregnancy have been published but chyluria presenting solely as a postpartum complication has rarely been documented. We present a case of a 29-year-old female with no known prior comorbidities, who presented with recurring complaints of the painless passage of milky white urine over the last year. Symptoms seem to have started six months post-delivery of her second child. The patient claimed significant weight gain during an otherwise normal pregnancy. She was well-built and had a BMI of 32 kg/m2. Her systemic examination and baseline laboratory workup were within normal limits. Postprandial urine was milky white, rich in chylomicrons, with urine chylomicrons of 112 mg/dl. The patient was screened for filariasis, which was negative. An ultrasound of the abdomen was done to rule out the presence of a fistula, but no evidence of one was found on imaging. Tc-99m sulfur colloid scintigraphy revealed an area of abnormal tracer accumulation in the abdomen with the passage of the tracer in the urine container, confirming the presence of chyluria. The patient was recommended to undergo conservative management with dietary modification and weight reduction. She has been closely followed up and has achieved spontaneous resolution of the chyluria. Most patients with chyluria show a good response to conservative management alone as in our case. Surgical intervention is usually indicated for cases not responding to conservative management or for refractory chyluria.

Recurrent Young Stroke With Hemianopia.

Homocysteine is a toxic, sulphur-containing intermediate of methionine metabolism. Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke. We present the case of a 39-year-old male who sustained a cerebrovascular accident with left hemiparesis two years back; the patient was not compliant with his medications, and now presented with complaints of giddiness, reduced vision, and double vision. Vision disturbances were bilateral, acute in onset, progressive over time, and predominantly affected the peripheral vision. On ophthalmic examination, homonymous hemianopia was noted, and finger counting was absent in both eyes. Confrontation test revealed a bilateral reduced field of vision more so in the left eye. Baseline investigations were unremarkable except for mildly elevated serum. Homocysteine and neuroimaging showed acute infarct with hemorrhagic transformation in the right occipito-parietal region and small acute non-hemorrhagic infarcts in the right thalamus and right side of the splfingerenium of the corpus callosum. Given the visual disturbance, Humphrey visual field (HVF) perimetry was done and it revealed left homonymous congruous hemianopia, likely due to right parietal lobe infarct. The patient had recurrent infarcts previously involving anterior and posterior circulation.

Role of secondary sepsis in COVID-19 mortality: Observations on patients with preexisting diabetes mellitus and newly diagnosed hyperglycemia.

Diabetics who develop severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) are more likely to have severe disease, higher odds of intensive care requirement and mortality. Fifteen percent of patients have new onset hyperglycemia. We studied the comparative outcomes between prior DM, newly detected hyperglycemia and assessed role of secondary sepsis on mortality. RWe performed a r etrospective study of confirmed SARS-CoV-2 patients at a tertiary care hospital in Chennai, India. Patients were divided as 2 groups (Group 1: With preexisting diabetes mellitus, Group 2: With newly diagnosed hyperglycemia due to newly detected diabetes mellitus or non-diabetic hyperglycemia. Clinical and laboratory data was analysed. Two hundred and thirty eight patients had prior-diabetes mellitus (Group 1) and 40 had newly diagnosed hyperglycemia (Group 2). Thirty four of group 1 and 7 of group 2 patients required intensive care. Mean capillary blood glucose (MCBG) during hospital stay was 207 mg/dl (Group 1) and 192 mg/dl (Group 2). Twentysix patients (9.3%) had secondary sepsis of which sixteen died. Logistic regression identified secondary sepsis(p<0.0001), elevated D-dimer >6 fold (p= 0.0001), elderly p=0.0045), male (p=0.0006), NLR >5 (p=0.01),serum creatinine ≥2 mg/dl (p=0.0004), FiO2 requirement >0.6 in first 48 hours (p=0.001) as mortality predictors.Our study observed a 14.38 % prevalence of newly diagnosed DM or non-diabetic hyperglycemia. Secondary sepsis and >6 fold elevation in D-dimer were strong predictors of mortality. Steroid use possibly contributed to secondary sepsis. Early identification and aggressive management of secondary sepsis are necessary for diabetics.

Comparison of Fasting Insulin Level, Homeostatic Model of Insulin Resistance, and Lipid Levels between Patients with Primary Hypertension and Normotensive Subjects.

BACKGROUND: Hyperinsulinemia and insulin resistance occurs in obese patients with primary hypertension independent of diabetes and obesity. This study was aimed at assessing serum fasting insulin levels, the homeostatic model assessment for insulin resistance (HOMA-IR), and serum lipid levels in non-obese patients with primary hypertension when compared to normotensive subjects. METHODS: This observational study comprised 100 patients over 18 years of age, divided into two groups. The hypertensive group comprised non-obese patients with primary hypertension (n=50); the normotensive group comprised normotensive age- and sex-matched individuals (n=50). Patients with diabetes, impaired fasting glucose, obesity, and other causative factors of insulin resistance were excluded from the study. Serum fasting insulin levels and fasting lipid profiles were measured, and insulin resistance was calculated using HOMA-IR. These data were compared between the two groups. Pearson's correlation coefficient was used to assess the extent of a linear relationship between HOMA-IR and to evaluate the association between HOMA-IR and systolic and diastolic blood pressures. RESULTS: Mean serum fasting insulin levels (mIU/L), mean HOMA-IR values, and fasting triglyceride levels (mg/dL) were significantly higher in the hypertensive versus normotensive patients (10.32 versus 6.46, P<0.001; 1.35 versus 0.84, P<0.001; 113.70 versus 97.04, P=0.005, respectively). The HOMA-IR levels were associated with systolic blood pressure (r value 0.764, P=0.0005). CONCLUSION: We observed significantly higher fasting insulin levels, serum triglyceride levels, and HOMA-IR reflecting hyperinsulinemia and possibly an insulin-resistant state among primary hypertension patients with no other causally linked factors for insulin resistance. We observed a significant correlation between systolic blood pressure and HOMA-IR.

Bedside Scoring System for Predicting Adverse Outcomes Among Patients Suffering From SARS-CoV-2 Infection.

Aim To develop a clinical risk score to predict adverse outcomes among diabetic hospitalized COVID-19 patients Methods The data was collected retrospectively from patients hospitalized with the SARS-CoV-2 virus at Sri Ramachandra Institute of Higher education and research. It integrated independent variables such as sex, age, glycemic status, socioeconomic status, and preexisting lung conditions. Each variable was assigned a value and the final score was calculated as a sum of all the variables. The final score was then compared with patient outcomes. The patients were scored from 0 to 8 and a score of 3 or more was considered as being at greater risk for developing complications. Number of mortalities in each group, any clinical deterioration requiring ICU admission, and the number of patients requiring a prolonged hospital stay of more than 10 days in each group were noted and the results compared. Results Higher blood glucose levels and preexisting lung conditions like chronic obstructive pulmonary disease (COPD), asthma, and pulmonary tuberculosis have been associated with a higher risk of developing complications related to SARS-CoV-2 illness. Of the 5023 patients enrolled in the study, 2402 had a score of 2 or below, and 2621 had a score of 3 or above. Among patients with a score of 2 or below 1.7% of the patients contracted a severe disease resulting in death. 2.9% were shifted to ICU, but recovered and 12.2% of patients had a prolonged hospital stay. Of those with a score of 3 or greater, 5.1% died, 7.36% were shifted to ICU, but recovered, and 19.5% required a prolonged hospital stay. The observed results were analyzed using the Chi-square test and were found to be significant at a p-level of 0.0001. Conclusion This clinical risk score has been built with routinely available data to help predict adverse outcomes in diabetic patients hospitalized with the SARS-CoV-2 virus. It is a good tool for resource-limited areas as it uses readily available data. It can also be used for other severe acute respiratory illnesses or influenza-like illnesses.

Course of COVID-19 Based on Admission D-Dimer Levels and Its Influence on Thrombosis and Mortality.

BACKGROUND: Arterial and venous thrombosis is one of the major complications of coronavirus disease 2019 (COVID-19) infection. Studies have not assessed the difference in D-dimer levels between patients who develop thrombosis and those who do not. METHODS: Our study retrospectively assessed D-dimer levels in all virus confirmed hospitalized patients between May to September, 2020. Patients were divided into three groups: group 1 with normal D-dimer of < 0.5 µg/mL, group 2 with elevation up to six folds, and group 3 with more than six-fold elevation. Statistical analysis was done using SPSS software 23.0. RESULTS: Seven hundred twenty patients (group1 (n = 414), group 2 (n = 284) and group 3 (n = 22)) were studied. Eight thrombotic events were observed. Events were two with stroke, two non-ST elevation myocardial infarction and one each of ST elevation myocardial infarction, superior mesenteric artery thrombosis with bowel gangrene, arteriovenous fistula thrombus and unstable angina. No significant difference (P = 0.11) was observed between median D-dimer levels among patients who developed thrombosis (1.34) and those who did not develop thrombosis (0.91). Twenty-nine patients died. The adjusted odds of death among those with a six-fold or higher elevation in D-dimer was 128.4 (95% confidence interval (CI): 14.2 - 446.3, P < 0.001), while adjusted odds of developing clinical thrombosis was 1.96 (95% CI: 0.82 - 18.2, P = 0.18). CONCLUSIONS: Our study observed a 1.1% in-hospital incidence of clinical thrombosis. While, a six-fold elevation in D-dimer was significantly associated with death; the same was not a strong predictor of thrombosis; an observation which implies that dose of anticoagulation should not be based on absolute D-dimer level.

Modeling the recovery time of patients with coronavirus disease 2019 using an accelerated failure time model.

OBJECTIVE: To identify factors associated with recovery time from coronavirus disease 2019 (COVID-19). METHODS: In this retrospective study, data for patients with COVID-19 were obtained between 21 June and 30 August 2020. An accelerated failure time (AFT) model was used to identify covariates associated with recovery time (days from hospital admission to discharge). AFT models with different distributions (exponential, log-normal, Weibull, generalized gamma, and log-logistic) were generated. Akaike's information criterion (AIC) was used to identify the most suitable model. RESULTS: A total of 730 patients with COVID-19 were included (92.5% recovered and 7.5% censored). Based on its low AIC value, the log-logistic AFT model was the best fit for the data. The covariates affecting length of hospital stay were oxygen saturation, lactate dehydrogenase, neutrophil-lymphocyte ratio, D-dimer, ferritin, creatinine, total leucocyte count, age > 80 years, and coronary artery disease. CONCLUSIONS: The log-logistic AFT model accurately described the recovery time of patients with COVID-19.

Unusual and rare case of generalised lymphadenopathy: Kimura's disease.

We report a case of Kimura's disease in a 65-year-old woman who presented with generalised itching, abdominal pain, facial puffiness, difficulty in swallowing and loss of appetite. She was found to have generalised lymphadenopathy and a fine-needle aspiration cytology initially done revealed 'reactive lymphadenitis' which was inconclusive. PET-CT done showed features suggestive of lymphoma. Hence, lymph node biopsy was done for confirmation and incidentally after immunohistochemistry staining it turned out to be Kimura's disease. High-dose steroid therapy was started and patient showed dramatic clinical and symptomatic improvement. Kimura's disease almost always presents as cervical lymphadenopathy and usually never causes compressive symptoms. Our patient presented with compressive symptoms and generalised lymphadenopathy which is a rarity.