A case report of Budd-Chiari syndrome with cardiac complications and low SPO2 successfully managed by an integrated-approach

Budd-Chiari syndrome [BCS] is a rare, potentially life-threatening condition characterized by the triad of abdominal pain, ascites, and hepatomegaly (with or without jaundice). There will be an underlying disorder in most cases. The diagnosis, as well as management of the case, requires a multidisciplinary approach. The treatment should aim at reducing the presenting symptoms as well as removing the underlying pathology. Here we explain a case report of a 21-year-old male patient in the subacute stage of BCS with its complications and considered as a candidate for liver transplantation. His liver enzymes, PT/INR, D- dimer, and homocysteine values were above normal levels. The arterial oxygen saturation level was subnormal, and he was on supportive oxygen supplement. Inferior venacava [IVC] Doppler revealed a non-obstructive intrahepatic thrombus. The patient was treated with Homoeopathic medicine Arsenicum album and Arnica montana, given as an adjuvant to conventional treatment.

Internal parasitic burdens in brown rats (Rattus norvegicus) from Grenada, West Indies.

This study identified the endoparasites in Brown rat (Rattus norvegicus) during May to July 2017 in Grenada, West Indies. A total of 162 rats, 76 females and 86 males were trapped from St. George and St. David parishes in Grenada. The collected fecal samples were examined for parasitic eggs and/or oocysts using simple fecal flotation technique. Adult parasites found in the intestinal tract were examined for identification. The overall prevalence of intestinal parasites among rats was 79 %. Ten helminth species were recovered, several of which were reported for the first time in rodents in Grenada. The internal parasites consist of seven nematodes (Angiostrongylus spp., Nippostrongylus braziliensis, Heterakis spumosa, Strongyloides ratti, Aspiculuris tetraptera, Syphacia spp. and Protospirura spp.), one cestode (Hymenolepsis diminuta), one acanthocephalan (Moniliformis moniliformis) and one protozoa species (Eimeria spp.). The most prevalent zoonotic species were Angiostrongylus spp. (35.2%), Hymenolepsis diminuta (7.4%) and Moniliformis moniliformis (3.1%). Several nonzoonotic endoparasites; which included Nippostrongylus braziliensis (50.6%), Heterakis spumosa (15.4%), Strongyloides ratti (43.2%), Aspiculuris tetraptera (2.5%), Syphacia spp. (1.9%), Protospirura spp. (1.2%) and Eimeria spp. (4.7%) were also identified. The most prevalent parasites were Nippostrongylus brasiliensis (50.6%), Strongyloides ratti (43.2%) and Angiostrongylus spp. (35.2%). Co-infections occurred with up to six species per rat showing different combinations of parasitic infections.

Prevalence of Cryptosporidium spp. in asymptomatic small ruminants in Grenada, West Indies.

Cryptosporidium spp. is a protozoan parasite that causes enteric infection in a wide range of hosts, including livestock and humans. The aim of this cross-sectional study was to estimate the prevalence of Cryptosporidium spp. in small ruminants in Grenada, West Indies. Fecal samples were collected from 100 sheep and 202 goats from 32 farms. The fecal samples were tested using an Enzyme-linked immunosorbent assay (ELISA) for qualitative detection of antigens in feces (Diagnostic Automation Inc., USA). The overall prevalence of Cryptosporidium spp. was 19.5% [95% confidence interval (CI): 15.4% to 24.4%] in both sheep and goats. The prevalence of Cryptosporidium spp. in sheep and goats was 14% (95% CI: 8.4% to 22.3%) and 22.3% (95% CI: 17.1% to 28.5%), respectively. There was no significant difference in the prevalence of Cryptosporidium spp. infection between sheep and goats (p = .42, Fisher's exact test) in Grenada. Of the 32 farms visited, 19 (59.4%) had at least one Cryptosporidium spp. positive animal.

The structure of turbulence in a rapid tidal flow.

The structure of turbulence in a rapid tidal flow is characterized through new observations of fundamental statistical properties at a site in the UK which has a simple geometry and sedate surface wave action. The mean flow at the Sound of Islay exceeded 2.5 m s-1 and the turbulent boundary layer occupied the majority of the water column, with an approximately logarithmic mean velocity profile identifiable close to the seabed. The anisotropic ratios, spectral scales and higher-order statistics of the turbulence generally agree well with values reported for two-dimensional open channels in the laboratory and other tidal channels, therefore providing further support for the application of universal models. The results of the study can assist in developing numerical models of turbulence in rapid tidal flows such as those proposed for tidal energy generation.

BK Virus Nephropathy: Histological Evolution by Sequential Pathology.

Reactivation of BK virus in renal allografts causes a destructive chronic infection. This single-center retrospective cohort study describes the evolution of BK virus allograft nephropathy (BKVAN) from 63 kidneys (from 61 patients) using sequential histopathology (454 biopsies, averaging 7.8 ± 2.6 per kidney) followed for 60.1 mo. Uninfected protocol biopsies formulated time-matched control Banff scores (n = 975). Interstitial inflammation occurred in 73% at diagnosis, correlating with viral histopathology (r = 0.413, p = 0.008) and amplifying early injury with accelerated interstitial fibrosis and tubular atrophy (IF/TA, p = 0.017) by 3 mo. Prodromal simian virus 40 large T antigen (SV40T)-negative inflammation with viremia preceded the histological diagnosis in 23.8%. Persistent subacute injury from viral cytopathic effect was associated with acute tubular necrosis and ongoing interstitial inflammation, culminating in IF/TA in 86.9%. Overall, cellular interstitial infiltration mitigated the intensity of subsequent tubular injury, SV40T, and tissue viral load, assessed by sequential paired histology (p < 0.001). Graft loss was predicted by high-level viremia (hazard ratio [HR] 4.996, 95% CI 2.19-11.396, p < 0.001), deceased donor (HR 3.201, 95% CI 1.149-8.915, p = 0.026), and late acute rejection (HR 3.124, 95% CI 1.037-9.413, p = 0.043). Transplant failure occurred in 38.1%, with uncontrolled infection (58.3%) and SV40T-negative chronic rejection (41.7%) causing losses. BKVAN is characterized by subacute virus-induced tubular injury, inflammation, and progressive nephron destruction. Effective antiviral therapy remains an unmet clinical need.

A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting.

CONTEXT: Metabolic acidosis is frequently found in patients with severe sepsis. An understanding of types of acidosis in sepsis and their evolution over the course of treatment may give us insight into the behavior of acid-base balance in these patients. AIMS: To describe at Intensive Care Unit (ICU) admission and over the first 5 days the composition of metabolic acidosis in patients with sepsis and to evaluate and compare acidosis patterns in survivors and nonsurvivors. SETTINGS AND DESIGN: A prospective study conducted at Amrita Institute of Medical Sciences, Kochi, Kerala, in the Department of Internal Medicine. SUBJECTS AND METHODS: Seventy-five consecutive patients admitted in the medical ICU with sepsis and metabolic acidosis were assessed. Arterial blood gas and serum electrolytes were measured during the first five days of admission or until death, renal replacement or discharge supervened. STATISTICAL ANALYSIS: To test the statistical significance of the difference in mean values of different study variables at day 1 and last day between survivors and non survivors, Mann-Whitney U-test was applied. To test the statistical significance of the difference in mean changes in different study parameters from day 1 to last day, paired t-test was done in the survivor group and Mann-Whitney U-test in the non survivor group. RESULTS: Regardless of survival status, on day 1 of admission, 37 had High Anion Gap metabolic acidosis (HAGMA), 21 had predominant lactic acidosis (LA), 8 had Normal anion gap metabolic acidosis (NAGMA), and 9 had both HAGMA and LA [Figure 1]. When we compared this to the last day, 25 had HAGMA, 3 had LA, 3 had both HAGMA and LA, and 22 patients had resolution of acidosis. Sixty-four patients survived for up to 5 days of admission. Fifteen of these patients underwent hemodialysis on the day of admission itself in view of HAGMA. The remaining 49 comprised of HAGMA (31), Lactic acidosis (12), and a combination (6) on day 1. On the last day in this group, 25 had HAGMA, 2 had LA, and 22 patients had resolution of acidosis. In survivors, over the observation period, changes seen were: mean pH: 7.25-7.34 (P < 0.001), mean serum bicarbonate: 13.9 mEq to 17.2 mEq (P < 0.001), and mean serum lactate: 3.18-1.9 (P = 0.002). The changes in serum albumin and pCO2 were not significant. Eleven patients in the study population succumbed. Seven patients underwent hemodialysis on day 1 and the remaining four were followed up for more than 1 day. On day 1, 7 had lactic acidosis and 5 had HAGMA. Over the observation period, changes seen were mean pH: 7.15-7.14, mean serum lactate: 6.3-7.3 mEq. CONCLUSIONS: In patients with sepsis and septic shock, high anion gap metabolic acidosis is the dominant blood gas anomaly. Fall in lactate levels over the first 5 days of admission is a good prognostic marker of survival. Evolution of the blood gas profile over time suggests that a fall in lactate levels and a rise in bicarbonate levels correlate with a better outcome. The role of the anion gap as a prognostic marker holds promise and further studies are needed in this regard.

Clinical and laboratory profile of dengue in the elderly.

BACKGROUND: Dengue is the most rapidly spreading mosquito-borne viral disease in the world with a 30-fold increase in incidence in the last 50 years. Approximately, 50 million dengue infections occur annually. AIM: To study the various clinical and laboratory manifestations of dengue in the elderly and observe for any variations in IgM titer elevation with progression of age. DESIGN: Retrospective observational study. SUBJECTS AND METHODS: Medical charts of all patients admitted to the Division of Geriatrics of the institute during study period were reviewed for collection of demographic, clinical, and laboratory information. The diagnosis of dengue was made based on positive dengue IgM ELISA. An elderly patient referred to one whose age was ≥60 years. RESULTS: Fever and myalgia were noted to be the most common clinical manifestation with only four patients presenting with overt bleeding manifestations. Only one patient presented in delirium and there was no case fatality. Thrombocytopenia was the single most common hematological abnormality noted. Hyponatremia was found to be prevalent in a majority of the patients and were symptomatic in more than half of them. There have been very few studies done worldwide on the varied clinical manifestations of dengue in the elderly.

Retrospective study of canine heartworm disease with caval syndrome in Grenada, West Indies.

Canine heartworm disease caused by Dirofilaria immitis is an important disease of dogs. The aim of this retrospective study was to estimate the prevalence of canine heartworm disease and evaluate cases of caval syndrome in dogs submitted for necropsy in Grenada. Out of 1617 dogs necropsied over a period of 13 years (2001-2013), 249 were found to be infected with D. immitis; giving an overall prevalence of 15.4% (95% confidence interval, 13.6% to 17.1%). There was no significant difference between male and female dogs with respect to canine heartworm infection (p = 0.3). During this period, the annual prevalence of canine heartworm disease was 22% in 2001 before slightly declining to an average of 18% in 2002-2003 and peaking at 26.8% in 2004-2005. From 2006 onwards, annual prevalence rates have steadily been decreasing; reaching the lowest (9%) in 2013. Among the 249 positive cases, 33 (13.2%) of the dogs had caval syndrome. Caval syndrome cases presented with concurrent clinical signs and were associated with cardio-pulmonary and hepatic gross lesions at necropsy. Aberrant migration of D. immitis was also noted in 2 dogs with caval syndrome. This is the first report which presents the findings of canine heartworm disease with caval syndrome in Grenada.

Seroprevalence of Trypanosoma cruzi in stray and pet dogs in Grenada, West Indies.

American trypanosomiasis (Chagas disease) caused by the protozoan parasite Trypanosoma cruzi is endemic to parts of South America and the Caribbean. Infected dogs are important in the epidemiology of the parasite as they can play a role in the transmission of the parasite to humans. A total of 399 dog sera (242 stray and 157 pet dogs) were examined for T. cruzi infection; using a qualitative immunochromatographic dipstick test, based on recombinant antigens specific for American trypanosomiasis (Trypanosoma detect rapid test; InBios international, Inc., Seattle, Washington). Overall seroprevalence for T. cruzi was estimated at 10.5% (95% confidence interval: 7.5% to 13.5%); with stray dogs being significantly more affected (p<0.05, χ2). Results from this study indicate that dogs in Grenada are moderately exposed to T. cruzi compared to other areas in the region.

Characteristics of the turbulence in the flow at a tidal stream power site.

This paper analyses a set of velocity time histories which were obtained at a fixed point in the bottom boundary layer of a tidal stream, 5 m from the seabed, and where the mean flow reached 2.5 m s(-1). Considering two complete tidal cycles near spring tide, the streamwise turbulence intensity during non-slack flow was found to be approximately 12-13%, varying slightly between flood and ebb tides. The ratio of the streamwise turbulence intensity to that of the transverse and vertical intensities is typically 1 : 0.75 : 0.56, respectively. Velocity autospectra computed near maximum flood tidal flow conditions exhibit an f(-2/3) inertial subrange and conform reasonably well to atmospheric turbulence spectral models. Local isotropy is observed between the streamwise and transverse spectra at reduced frequencies of f>0.5. The streamwise integral time scales and length scales of turbulence at maximum flow are approximately 6 s and 11-14 m, respectively, and exhibit a relatively large degree of scatter. They are also typically much greater in magnitude than the transverse and vertical components. The findings are intended to increase the levels of confidence within the tidal energy industry of the characteristics of the higher frequency components of the onset flow, and subsequently lead to more realistic performance and loading predictions.

Spirocercosis in owned and stray dogs in Grenada.

The aim of this retrospective study was to estimate the prevalence of Spirocerca lupi and its associated lesions in owned and stray dogs in Grenada. During 2001-2011 necropsies were carried out on 1022 owned and 450 stray dogs at the pathology diagnostic laboratory, School of Veterinary Medicine, St. George's University, Grenada. Lesions due to S. lupi characterized by focal to multifocal granulomatous esophagitis with aneurysms, mineralized plaques and nodules in the adjacent thoracic aorta were found in 90 (8.8%; 95% confidence interval, 7.1-10.5%) of owned dogs and 64 (14.2%; 95% CI, 11.2-17.6%) of stray dogs. Stray dogs were significantly more affected by spirocercosis than owned dogs (p=0.0022). Of the 90 owned dogs with spirocercosis, 3 dogs had aberrant migration to the thoracic vertebral column with resultant spondylitis; 1 dog each had aberrant migration involving the stomach and the lung. Two dogs had ruptured aorta with hemothorax. Among the 64 stray dogs with spirocercosis, one dog had an esophageal granuloma that transformed into a fibroblastic osteosarcoma; spondylitis due to aberrant migration of S. lupi and hypertrophic osteopathy. We report spirocercosis for the first time in the dogs from a tropical island of Grenada.

Seroprevalence of Toxoplasma gondii in pigs, sheep, goats, and cattle from Grenada and Carriacou, West Indies.

Prevalence of Toxoplasma gondii infection in pregnant women in Grenada is considered high. Little is known of the epidemiology of T. gondii infection in Caribbean Islands. Serum samples of 750 food animals in Grenada and Carriacou were tested for antibodies to T. gondii by the modified agglutination test (MAT). Antibodies to T. gondii (MAT, 1∶25 or higher) were found in 23.1% of 247 pigs, 44.1% of 204 sheep, 42.8% of 180 goats, and 8.4% of 119 cattle. Seroprevalence increased with age, indicating postnatal acquisition of T. gondii. Antibody titers of 1∶200 or higher were present in 65 of 90 seropositive sheep, 61 of 77 seropositive goats, and 23 of 57 seropositive pigs. However, none of the cattle had a MAT titer of 1∶200, suggesting that bovines are a poor host for T. gondii. Results indicate that pigs, sheep, and goats could be important sources of T. gondii infection if their meat is consumed undercooked.

Neoplastic and nonneoplastic cutaneous tumors of dogs in grenada, west indies.

This retrospective survey was undertaken between 2002 and 2007 on samples from dogs residing in Grenada. The objectives of the study were to identify the most common histologic types of canine cutaneous tumors, determine the relative frequency of each tumor type, and compare results to reports from other regions. In a series of 225 skin masses examined, the proportion of neoplasms was 72% whereas nonneoplastic tumors accounted for 15.6%, and inflammatory conditions constituted 12.4%. There were 10 types of nonneoplastic tumors with hamartomas being the most common (28.5%), followed by sebaceous hyperplasia (25.7%) and fibroepithelial polyps (22.8%). The 10 most common cutaneous neoplasms were hemangiosarcomas (19.1%), histiocytomas (8.6%), melanocytomas (8%), mast cell tumors (6.8%), lipomas (6.8%), hemangiopericytomas (6.2%), papillomas (5.6%), fibrosarcomas (5.6%), hemangiomas (4.9%), and squamous cell carcinomas (4.3%). Tumors of vascular origin and transmissible venereal tumors were more common in dogs in our study than reported from other regions.

Preliminary molecular characterization of a fowl poxvirus isolate in Grenada.

Two 1-mo-old local breed chickens, with gross lesions in the skin of the head region suspected to be fowl poxvirus infection, were submitted to the Diagnostic Laboratory of the School of Veterinary Medicine, Grenada, West Indies. Cutaneous lesions were collected from these birds for virus isolation, histopathologic diagnosis, and molecular analysis. Fowl poxvirus infection was confirmed by virus isolation in chicken embryo and by histopathology. Molecular characterization of the fowl poxvirus was conducted by PCR amplification of selected genomic fragments and by nucleotide sequencing. Integration of reticuloendotheliosis virus fragments into the fowl poxvirus genome was confirmed by PCR and DNA sequencing. This is the first report from the Caribbean region on the preliminary molecular characterization of a fowl poxvirus isolate.

A serological study of Dirofilaria immitis in feral cats in Grenada, West Indies.

A study to determine the seroprevalence of Dirofilaria immitis was carried out in feral cats in Grenada. Of the 137 feral cats tested for circulating antibodies (IgG; lateral-flow immunoassay) and circulating antigens (Ag; enzyme-linked immunosorbent assay), 8% (95% confidence interval (CI) 3.5-12.5%) were antibody positive and 5.1% (95% CI 1.4-8.8%) were antigen positive. No significant difference between cats aged>1 to 4 years and cats less than 1 year of age was found (P>0.05, χ²). There was also no significant difference (P>0.05, χ²) between male and female cats. Dirofilaria immitis prevalence is relatively high in the feral cat population of Grenada. Evidence of D. immitis infection in feral cats coupled with the endemic nature of heartworm disease in dogs in Grenada leads us to suggest the introduction of heartworm prophylaxis in cats. To the authors' knowledge, this serological evidence of heartworm infection in feral cats in Grenada is the first report from the Caribbean region.

Seroprevalence of canine leishmaniasis and American trypanosomiasis in dogs from Grenada, West Indies.

Canine leishmaniasis and American trypanosomiasis (AT) are caused by related hemoflagellated parasites, Leishmania spp. and Trypanosoma cruzi, which share several common host species. Dogs are reservoirs for human infections by both pathogens. We determined the prevalence of antibodies to Leishmania spp. and T. cruzi in dogs from Grenada, West Indies. We examined 70 dog sera using the qualitative immunochromatographic dipstick tests (ICTs) based on recombinant antigens specific for visceral leishmaniasis and AT. Antibodies to visceral Leishmania were not detected in Grenadian dogs by ICT. Using the canine dipsticks for AT, antibodies to T. cruzi were determined in 3 (4.3%) of the 70 dogs. Results from this study indicate that dogs in Grenada are exposed in low levels to T. cruzi , but not to visceral Leishmania spp. at all.

Seroprevalence of Toxoplasma gondii and concurrent Bartonella spp., feline immunodeficiency virus, and feline leukemia virus infections in cats from Grenada, West Indies.

Toxoplasma gondii and Bartonella spp. are zoonotic pathogens of cats. Feline immunodeficiency virus (FIV) and feline leukemia virus (FeLv) are related to human immunodeficiency virus, and human leukemia virus, respectively; all of these viruses are immunosuppressive. In the present study, the prevalence of antibodies to T. gondi, Bartonella spp., FIV, as well as FeLv antigen were determined in sera from 75 domestic and 101 feral cats (Felis catus) from the Caribbean island of Grenada, West Indies. Using a modified agglutination test, antibodies to T. gondii were found in 23 (30.6%) of the 75 pet cats with titers of 1:25 in 1, 1:50 in 3, 1:400 in 4, 1:500 in 12, 1:800 in 2, and 1:1,600 in 1, and 28 (27.7%) of 101 feral cats with titers of 1:25 in 4, 1:50 in 7, 1:200 in 4, 1:400 in 1, 1:500 in 3, 1:800 in 2, 1:1,600 in 3, and 1:3,200 in 4. Overall, in both pet and feral cats, the seroprevalence increased with age. Antibodies to Bartonella spp. were found in 38 (50.6%) of the 75 pet cats and 52.4% of 101 feral cats. Antibodies to FIV were found in 6 domestic and 22 feral cats. None of the 176 cats was positive for FeLv antigen. There was no correlation among T. gondii, Bartonella spp., and FIV seropositivity.