Tumor necrosis factor-alpha levels in patients with HIV with wasting in South Asia.

Tumor necrosis factor (TNF)-alpha is thought to play an important role in wasting; but TNF-alpha levels have not been consistently found to be high in AIDS wasting. We conducted this study to determine any correlation between TNF-alpha levels and wasting in HIV-positive patients in a developing country. TNF-alpha levels were measured in four groups of patients: Group 1, HIV/AIDS with wasting (n = 25); group 2, HIV/AIDS without wasting (n = 47); group 3, HIV-negative patients with tuberculosis with wasting (n = 25); and group 4, healthy controls (n = 25). Wasting was defined as a body bass index (BMI)

Bleomycin-induced scleroderma.

Systemic sclerosis is a connective tissue disease, which can be triggered by environmental factors. We report one such case of bleomycin-induced scleroderma.

In vivo proton magnetic resonance spectroscopy (MRS) and single photon emission computerized tomography (SPECT) in systemic lupus erythematosus (SLE).

Neuropsychiatric involvement in SLE (NP-SLE) may not be picked up by routine neuroimaging procedures like computerized tomography (CT) or magnetic resonance imaging (MRI). We prospectively studied the role of single photon emission computerized tomography (SPECT) and magnetic resonance spectroscopy (MRS) in detection of NP-SLE in 20 patients with lupus (10 with clinical NP involvement and 10 without) and 9 healthy controls. MRI abnormalities were seen in 5/10 patients with NP-SLE while the MRI was normal in all the lupus patients without clinical NP involvement. Perfusion defects on SPECT were seen in as many as 8/10 patients with NP-SLE while only 1/10 lupus patients without clinical NP involvement and none of the healthy controls demonstrated perfusion defects. MRS revealed abnormal metabolite ratios in all patients with NP-SLE and as many as 8 lupus patients without clinical NP features. Normal metabolite ratios were observed in healthy controls. SPECT and MRS can help detect changes not evident on MRI and may serve as useful supplements to existing neuroimaging techniques in the diagnosis of NP-SLE. The precise significance of alterations in regional cerebral blood flow on SPECT and neurometabolite ratios on MRS needs larger, longitudinal studies.

Panniculitides--a clinicopathologic study.

OBJECTIVES: To describe the clinical and pathologic features of panniculitides, an uncommon group of diseases, where the available Indian literature is sparse. MATERIAL AND METHODS: Prospective four years study of patients presenting with panniculitis to a large teaching hospital in North India. RESULTS: Erythema nodosum (EN) was the commonest panniculitis (79.3% cases) in our cohort. Other causes included erythema induratum, Weber Christian disease, cutaneous polyarteritis nodosa and panniculitis associated with Takayasu's arteritis and dermatomyositis-lupus overlap. Elevated ESR and leukocytosis were the common laboratory abnormalities encountered. Septal panniculitis without vasculitis was the most frequent histopathologic pattern observed. Patients of EN did well on nonsteroidal anti-inflammatory drugs while corticosteroids with or without azathioprine were used to treat other panniculitides. CONCLUSIONS: Physician awareness, clinical pattern recognition and histopathological confirmation, all play a key role in the identification and management of panniculitis.

Giant cell arteritis--a rare cause of fever of unknown origin in India.

Giant cell arteritis (GCA) is a systemic large vessel vasculitis. Awareness of various manifestations of GCA is essential for early recognition and prompt treatment so as to prevent complications like blindness. GCA is one of the relatively common causes of fever of unknown origin (FUO) in the elderly in USA and Europe. However, no such cases have been reported from India. A case of GCA presenting as FUO is reported and the literature reviewed.

Seroepidemiology and active surveillance of dengue fever/dengue haemorrhagic fever in Delhi.

The aims of the present study were to carry out surveillance for dengue virus infection in adults with short-duration fever, and serological study of dengue virus infection in persons without fever. Patients were divided into two groups. Group 1 included patients above 12 years of age with fever of 2-12 days duration without any apparent cause. Of these, patients who presented with fever for 2-5 days were included for virus isolation (group 1a) while those who presented within 6-12 days of the onset of fever were included for the dengue-specific IgM serology (group 1b). Group 2 included a sample of population belonging to all age groups but without pyrexia and blood was collected for dengue-specific IgG serology. Twenty-six patients were enrolled in group 1a over a period of 4 months (September to December, 1997). Of these, DEN1 was isolated in 5 cases. Group 1b included 182 patients, out of which 34 (18.68%) were positive for dengue-specific IgM antibodies. Significantly, all the positive cases were detected during the months of September to November. Retro-orbital pain was present in a significantly more number of IgM-positive cases as compared to IgM-negative cases. Group 2 included 125 cases without fever. The overall positivity for dengue-specific IgG antibodies was 77.6%, with the highest positivity of 100% in the age group of 31-40 years. It was concluded that dengue virus infection is endemic in and around Delhi with peak incidence between September and Novemver. The prevalent serotype during September and December 1997 was DEN1. Since previous epidemic of DHF was due to DEN2 type, isolation of DEN1 serotype indicates changes of another epidemic of DHF due to DEN1 serotype. The stresses the urgent need for implementation of measures to control the transmission of dengue infection.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study.

OBJECTIVE: To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA). MATERIAL AND METHODS: Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study. RESULTS: We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA. CONCLUSIONS: The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

A clinico-bacteriological study of peripheral tuberculous lymphadenitis.

OBJECTIVE: Tuberculous lymphadenitis is the commonest form of extra-pulmonary tuberculosis. It is most often caused by M. tuberculosis though several reports from other countries have shown mycobacteria other than tuberculosis (MOTT) to be responsible for a significant proportion of tuberculous lymphadenitis cases. The present study was conducted to find the prevalence of M. tuberculosis and MOTT as aetiological agents in patients with peripheral tuberculous lymphadenitis. METHODS: A total of 138 patients with tuberculous lymphadenitis were included in the study. Diagnosis of tuberculosis was established on the basis of fine needle aspiration cytology, histopathology, presence of mycobacteria on Ziehl Neelson stain or auramine rhodamine stain, or aspiration of pus with negative Gram's stain and pyogenic cultute with radiologic evidence of pulmonary tuberculosis. Mycobacterial cultures were performed on aspirated material and species identified using standard methods. RESULTS: Of 138 patients, single lymph nodal enlargement was found in 48.6% patients while others had more than one lymph nodes. Lymph nodes were matted in 26.8% cases while fluctuation could be elicited in 12.3% patients. Chest X-ray showed evidence of active pulmonary lesions or mediastinal lymphadenopathy in 28.3% cases. The fine needle aspiration cytology was positive for tuberculous lymphadenitis in 41.3% cases while it revealed granulomas or necrosis in another 13% cases. The Ziehl-Neelson and the auramine-rhodamine staining were positive in 19.6% and 26.8% patients, respectively. On culture, the lymph node aspirate was positive for Mycobacterium species in 40.6% patients. In all but two cases, the culture revealed presence of Mycobacterium tuberculosis. The other two cultures revealed growth of Mycobacterium fortuitum chelonae complex. Of the two HIV-positive patients, M. tuberculosis could be isolated in one case. CONCLUSION: Findings of this study suggest that M. tuberculosis is still the most common cause of tuberculous lymphadenitis and MOTT are responsible for very few cases. However, such studies need to be carried out frequently at various centres so as to see any periodic and geographic variations within India.

A study of autoimmune markers in hepatitis C infection.

BACKGROUND & OBJECTIVES: Hepatitis C virus (HCV) infection is associated with several autoimmune markers. Despite HCV being common in India, no information on this aspect is available. This study was undertaken to ascertain the frequency and clinical significance of autoimmune markers like rheumatoid factor (RF), antinuclear antibodies (ANA), antibodies to double stranded deoxyribonucleic acid (dsDNA), anti neutrophil cytoplasmic antibody (ANCA), anti smooth muscle antibodies (ASMA), anti liver kidney microsomal 1 antibodies (anti LKM1), anti gastric parietal cell antibodies (anti GPCA), anti mitochondrial antibodies (AMA), anti cardiolipin antibodies (ACL) and cryoglobulins in HCV infection and to determine the effect of treatment on these markers. METHODS: Twenty five patients with chronic hepatitis C and 25 healthy controls were studied. Cryoglobulins were detected by cryoprecipitation, RF by latex agglutination, anti dsDNA and ACL by ELISA while indirect immunofluorescence was used to detect all other autoantibodies. RESULTS: Eighteen patients (72%) demonstrated autoimmune markers. RF, cryoglobulins and anti LKM1 antibodies were the most frequently detected markers (in 32% patients each). ASMA, perinuclear ANCA (pANCA), ANA and anti GPCA were seen in 24, 20, 12 and 4 per cent patients respectively. None of the patients exhibited ACL, AMA or antibodies to dsDNA. No antibodies were detected in healthy controls. Sixty per cent of the patients had rheumatological symptoms. Of the seven patients followed up after treatment with alpha interferon, only two exhibited persistence of RF, while symptoms and other markers disappeared. INTERPRETATION & CONCLUSION: Rheumatological symptoms and autoimmune markers are common in HCV infection and are usually overlooked. Patients with unexplained joint pains and/or palpable purpura should be screened for HCV. Further studies are needed to delineate fully the link between infection and autoimmunity.

Ultrasonographic assessment of gall bladder kinetics in the elderly.

BACKGROUND: The incidence of gallstones increases with age but the factors that influence gallstone formation in the elderly are poorly understood. Proposed factors include changes in bile composition and hypomotility of the gall bladder. Studies on gall bladder motility in the elderly have provided conflicting results, and none has been reported from India. AIM: To determine gall bladder contractility in healthy elderly subjects and compare it with that in young healthy volunteers. METHODS: Thirty healthy elderly (above the age of 60 years) and 30 young volunteers with no abdominal complaints were studied. Using real-time ultrasonography and the ellipsoid method, gall bladder volume was measured after overnight fast and at 10, 20, 30, 40, 50 and 60 minutes after a standard fatty meal. Residual volume, delta volume and ejection fraction were calculated. RESULTS: Mean fasting gall bladder volume in elderly subjects was higher than that in young subjects (13.5 [5.8] mL vs 10.9 [3.6] mL; p < 0.05). However, there was no difference in the 60-min postprandial residual gall bladder volumes in the two groups. Change in gall bladder volume and ejection fraction were also similar in the two groups. CONCLUSION: There was no difference in gall bladder emptying between elderly and young subjects though the fasting gall bladder volume was higher in the elderly.

Hepatitis B, C and human immunodeficiency virus infections in multiply-injected kala-azar patients in Delhi.

Sera from 164 patients with parasitologically confirmed kala-azar and 100 patients with non-kala-azar Delhite in 2 Delhi hospitals were tested for anti-human immunodeficiency (anti-HIV) and anti-hepatitis C virus (anti-HCV) antibodies and hepatitis B surface antigens to determine which group is more likely to contract these infections. The mean age of the patients was 32.5 y (+/-6.5 y), (120 M, 44 F). Two patients were from Nepal and the others from the kala-azar endemic state of Bihar, India. As geographical controls, 50 serum samples from sex- and age-matched healthy Bihar residents were also tested for the blood-borne viral infections. All patients had been treated with injectable medicines by 1 or more local physicians before they were referred to the Delhi hospitals. The prevalence of hepatitis B virus (HBV) and HCV infection was significantly different between the 2 patient groups. While 2 kala-azar patients (1.21%) were found to be HIV-1 positive, 54 (32.9%) patients had anti-HCV antibodies detected by ELISA and 51 (31.1%) by RIBA test. The seroprevalence of HCV was only 2% in hospitalized non-kala-azar cases and 4% in the geographical controls (p < 0.001). The seroprevalence of HBV was 13.2% in hospitalized kala-azar cases, but only 1.75% in disease control cases and 1.6% in geographical control cases. The difference in infection rates between cases and controls was significant (p < 0.001). The results indicate that kala-azar patients treated locally in Bihar have a greater chance of contracting blood-borne infections. Interestingly, we found that HCV was more prevalent than HBV. These infections were most likely acquired through the re-use of needles by local medical and paramedical practitioners for administering anti-leishmanial drugs. This trend, if not checked immediately, may have drastic consequences in the horizontal transmission of HIV in Bihar.

Doxycycline in the treatment of rheumatoid arthritis--a pilot study.

OBJECTIVE: To assess the efficacy and safety of doxycycline as a disease modifying anti-rheumatic drug (DMARD) in rheumatoid arthritis (RA) and compare it with methotrexate, a standard DMARD. MATERIAL AND METHODS: A single (assessor) blind prospective study with 15 patients of RA randomized to doxycycline and 14 to methotrexate. Baseline disease characteristics were similar in both groups. RESULTS: All disease activity measures studied viz. tender and swollen joint counts, physician and patient global assessment, visual analogue pain scale, health assessment questionnaire and ESR improved in both the treatment groups after six months of treatment. The difference between doxycycline and methotrexate was not statistically significant. No major side effects necessitating drug withdrawal were reported from either group. The side effects were few and mostly gastrointestinal. CONCLUSION: Doxycycline is a safe disease modifying drug in RA whose effect is sustained at six months. It compared favourably with methotrexate over a six month follow up.

A prospective study of Lyme arthritis in north India.

Twenty seven patients presenting with mono/oligoarticular disease of unknown etiology were prospectively screened for Lyme arthritis. In addition, 12 healthy blood bank donors, 25 individuals with rheumatoid arthritis (disease controls), and 20 deer handlers and veterinarians were also screened for IgG antibodies to Borrelia burgdorferi. Only one patient tested borderline positive for antibodies to B. burgdorferi (more likely false positive). None of the healthy subjects, disease controls or occupationally exposed individuals exhibited serological evidence of exposure to B. burgdorferi. Screening for Lyme disease may not be warranted while investigating mono/oligoarthritides of unknown etiology in this part of the country.

Intravascular hemolysis in aluminium phosphide poisoning.

Intravascular hemolysis is most often secondary to exposure to a variety of drugs or infections, and usually occurs in patients who are deficient in glucose-6-phosphate dehydrogenase (G-6-PD) enzyme. Aluminium phosphide, a fumigant widely used in India, has been reported to produce intravascular hemolysis in only one patient who also had concomitant G-6-PD deficiency. This report describes the occurrence of intravascular hemolysis with aluminium phosphide poisoning in a patient with normal G-6-PD levels. This is of significance as jaundice in patients with this poisoning is often attributed to hepatic damage alone.

Dengue haemorrhagic fever in adults: a prospective study of 110 cases.

One hundred and ten adult patients hospitalized with dengue haemorrhagic fever (DHF) during the recent outbreak in North India were prospectively studied. Of these, 48 (43.6%) were grade I, 40 (36.4%) grade II, 10 (9.1%) grade III and 12 (10.9%) grade IV DHF. Dengue shock syndrome (DSS) was seen in 22 (20%) patients. Fever, headache, myalgias and arthralgias were the common symptoms seen in 100%, 80.9%, 76.2% and 52.3% patients, respectively. Spontaneous bleeding was seen in 62 patients (56.4%) with mucocutaneous bleeding being the most common (46 patients). Gastrointestinal bleeding was seen in 38 (34.5%) patients. In as many as 40 patients, the haemorrhagic manifestations occurred after the fever had come down. Fifty-five patients (50%) required platelet transfusions. Twelve patients died, giving a mortality rate of 10.9% in the present study. Prompt recognition and supportive treatment can be lifesaving.

Poncet's disease in a north Indian hospital.

Although the entity of tuberculous rheumatism or Poncet's disease has sometimes been the subject of debate, it has been reported infrequently in the English literature. We discuss here seven patients (5 women, 2 men; age 18-48 years) who presented primarily with polyarthritis and fever and developed pulmonary, pleural or nodal tuberculosis later in the course of disease. Rheumatoid arthritis, collagen vascular diseases and other common causes of polyarthritis were ruled out by appropriate investigations. Polyarthritis resolved in all the patients after the institution of antitubercular treatment and did not recur, thus providing a therapeutic confirmation of the clinical diagnosis.