Severe dengue infection unmasking drug-induced liver injury: Successful management with N-acetylcysteine.

Key Clinical Message: Clinicians in tuberculosis and dengue endemic regions should have heightened vigilance for drug-induced liver injury (DILI) overlapping with active infections, enabling prompt recognition and life-saving conservative management. Abstract: Severe dengue and drug-induced liver injury (DILI) are significant independent risk factors for acute liver failure. The co-occurrence of these conditions significantly complicates clinical management. Here, we describe the case of a 21-year-old Nepali female who developed acute liver failure during antitubercular therapy (ATT). The patient, presenting with fever and nausea after 3 weeks of ATT, subsequently received a diagnosis of severe dengue. Laboratory evidence indicated markedly elevated transaminases (AST 4335 U/L, ALT 1958 U/L), total bilirubin (72 µmol/L), and INR (>5). Prompt discontinuation of first-line ATT, initiation of a modified ATT regimen, and N-acetylcysteine (NAC) infusion facilitated the patient's recovery after a week of intensive care. This case underscores the potential for synergistic hepatotoxicity in regions where multiple endemic illnesses coincide. Early recognition of DILI, cessation of offending agents, and comprehensive intensive care are crucial interventions. While the definitive efficacy of NAC remains under investigation, its timely administration in these complex cases warrants exploration for its potential lifesaving benefits.

Advantage of neuroeducation in managing mass psychogenic illness among rural school children in Nepal.

Introduction: Mass psychogenic illness (MPI), also known as mass hysteria (MH), is a mental health disorder that frequently occurs in Nepal. It primarily affects female students in government high schools and occurs during the course of the school day over a few days without corresponding organic causes. Purpose of the study: This study set out to evaluate and give neuroeducation with the goal of preventing and/or managing MPI after documenting the existing state of knowledge regarding MPI. Materials and methods: A total of 234 female students in grades 6 through 10 who attended MH-affected schools (SMH, n = 119) and schools without a mass hysteria history (SNOMH, n = 114) participated in this mass hysteria awareness study. Participants received written pre- and posttests formatted as questionnaires before and after receiving neuroeducation by watching a drama, viewing a human brain-spinal cord model demonstration, and attending an instructive lecture on the human neurological system, stress, and mass hysteria. Results: Our neuroeducation awareness study on mass hysteria was found to be effective among all of the participants from both SMH and SNOMH. The results indicated that the aforementioned neuroeducation tools are more effective in improving knowledge about mental stress differently in different grades of SMH and SNOMH students. The basic understanding of the human neurological system was not improved by the neuroeducation tool, according to our findings. Conclusion: Our study suggests that using day-structured neuroeducational tools might be an efficient way to treat mass psychogenic illness in Nepal.

Essential Thrombocythemia among Patients with Myeloproliferative Neoplasms in Haematology Unit of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Essential thrombocythemia, a myeloproliferative condition with an increased number of circulating platelets, is a rare hematological malignancy. The aim of the study is to find out the prevalence of essential thrombocythemia among patients with myeloproliferative neoplasms presenting in haematology unit of a tertiary care centre. Methods: This was a descriptive cross-sectional study at a tertiary care centre from September, 2020 to September, 2021 (Reference number: 48 (6-11) E2077/076). All the patients with a diagnosis of essential thrombocythemia and willing to give consent were included in the study while the patients with incomplete investigations were excluded. A sample size of 72 patients was taken and convenience sampling was done. Data were entered in Microsoft Excel 2010 and analysis was done by the Statistical Package for the Social Sciences Version 22.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data along with mean and standard deviation for continuous data. Results: Among 72 patients with myeloproliferative neoplasms, the prevalence of essential thrombocythemia was found to be 17 (23.61%) (13.80-33.42 at a 95% Confidence Interval). The mean age of patients was 55.41±11.20 years with a male to female ratio of 9:8. The mean hemoglobin level and platelet count in patients were found to be 11.20±2.1 g/dl and 677000±262067.70 cells/mm3. Twelve (70.58%) of total patients were under low risk of essential thrombocythemia while 3 (17.64%) of them were at high risk. Conclusions: The prevalence of essential thrombocythemia was similar to other studies done in similar settings. Keywords: essential thrombocythemia; hematology; mutation.

New-onset diabetes in COVID-19 and clinical outcomes: A systematic review and meta-analysis.

BACKGROUND: Diabetes mellitus (DM) is associated with adverse clinical outcomes and high mortality in patients with coronavirus disease 2019 (COVID-19). The relationship between diabetes and COVID-19 is known to be bidirectional. AIM: To analyze the rate of new-onset diabetes in COVID-19 patients and compare the clinical outcomes of new-onset diabetes, pre-existing diabetes, hyperglycemic, and non-diabetes among COVID-19 patients. METHODS: We used the Meta-analysis of Observational Studies in Epidemiology statement for the present meta-analysis. Online databases were searched for all peer-reviewed articles published until November 6, 2020. Articles were screened using Covidence and data extracted. Further analysis was done using comprehensive meta-analysis. Among the 128 studies detected after thorough database searching, seven were included in the quantitative analysis. The proportion was reported with 95% confidence interval (CI) and heterogeneity was assessed using I 2. RESULTS: Analysis showed that 19.70% (CI: 10.93-32.91) of COVID-19 patients had associated DM, and 25.23% (CI: 19.07-32.58) had associated hyperglycemia. The overall mortality rate was 15.36% (CI: 12.57-18.68) of all COVID-19 cases, irrespective of their DM status. The mortality rate was 9.26% among non-diabetic patients, 10.59% among patients with COVID-19 associated hyperglycemia, 16.03% among known DM patients, and 24.96% among COVID-19 associated DM patients. The overall occurrence of adverse events was 20.52% (CI: 14.21-28.70) among COVID-19 patients in the included studies, 15.29% among non-diabetic patients, 20.41% among patients with COVID-19 associated hyperglycemia, 20.69% among known DM patients, and 45.85% among new-onset DM. Meta-regression showed an increasing rate of mortality among new hyperglycemic patients, known diabetics, and new-onset DM patients in comparison to those without diabetes. CONCLUSION: A significantly higher rate of new onset DM and hyperglycemia was observed. Higher mortality rates and adverse events were seen in patients with new-onset DM and hyperglycemia than in the non-diabetic population.

Comparative Study of Slow Infusion versus Bolus Doses of Albumin and Furosemide Infusion to Mobilize Refractory Ascites in Decompensated Chronic Liver Disease.

BACKGROUND: Combined use of furosemide with albumin is an approved therapy to overcome diuretic resistance in treatment of ascites in decompensated chronic liver disease. Bolus dosing of diuretics has its own limitations due to pre-existing hypotension, post diuretic sodium retention and braking phenomenon. Slow albumin and furosemide Infusion has been shown to mobilize large ascites with improved diuresis and hemodynamic stability in decompensated chronic liver disease. This study was undertaken to compare efficacy and safety of infusion therapy vs bolus therapy in term the management of refractory ascites. METHODS: Decompensated chronic liver disease patients with refractory ascites were randomly assigned into two groups of 15 each - Bolus therapy (intravenous albumin and furosemide as boluses) and Infusion therapy (furosemide infusion at 2mg/hour and albumin at 2g/hour for three days). Diuresis, natriuresis, change in abdominal girth and body weight, and hemodynamic stability (change in SBP) were compared between the two groups. RESULTS: Infusion therapy, as compared to bolus therapy, showed a significantly better diuresis (mean urinary output increment 483ml vs 243ml, p <0.001), natriuresis (mean urinary sodium excretion increment 35.2 mEq/L vs 16.6 mEq/L, p = 0.004),decrease in abdominal circumference (6.1cm vs 3.0cm, p<0.001) and decrease in body weight (5.53 Kg vs 2.86 Kg, p < 0.001). The complications of renal impairment were also lower in the Infusion group. CONCLUSION: Infusion of furosemide and albumin is a potential safer and effective therapeutic option in the management of refractory ascites with better natriuresis, higher urine output, and higher decrement in abdominal circumference and body weight, and lesser side effects.

Prevalence of Covert Hepatic Encephalopathy in A Tertiary Care Centre.

INTRODUCTION: Among patients with Hepatic Encephalopathy, prevalence of Minimal HE varies between 30-50%. Identifying patients with MHE has been shown to improve with medications and delay development of Overt HE, however only limited clinicians screen for MHE in patients due to time consuming neuropsychological and neurophysiological tests. The Number Connection Test is an easy way to evaluate patients to diagnose MHE. The aim of this study is to find out the prevalence of covert hepatic encephalopathy. METHODS: The descriptive cross-sectional study was done to find out the prevalence of covert hepatic encephalopathy among patients with chronic liver disease. To diagnose Covert HE which included MHE as well, NCT was used in Devanagari script. RESULTS: The prevalence of covert hepatic encephalopathy is found to be 56 (58.3%) at 90% confidence interval (58.23-58.37%). A total of 96 patients (71.9% male) were diagnosed as HE, with mean age of 49.6+11.8 years. The cause of CLD in 85 (88.5%) of these patients was alcohol, of which 76 (79.2%) consumed locally brewed alcohol. Of these 96 patients with HE, only 40 (41.7%) had overt HE. Among all these, maximum patients had MHE (37.5%). CONCLUSIONS: Our study showed that although the prevalence of minimal HE is quite high among cirrhotics, they are usually missed in clinical practice due to absence of symptoms. Active screening with easy-to-administer tests, like Number Connection tests, can help identify patients with minimal HE and hence treat them early.

Extraintestinal Clostridium difficile infection: Scrotal abscess.

Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. ExtraintestinalC. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due toC. difficile in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy.