Brain Abscess Caused by Lactococcus Lactis in a Young Male.

Lactococcus lactis cremoris is one of the gram positive cocci, not known to be pathogenic in humans. We report a case of brain abscess due to lactococcus lactis in an adolescent. An 18-year male with congenitally corrected transposition of great arteries and dextrocardia was admitted with fever, headache and right-sided numbness. Magnetic resonance imaging revealed a well circumscribed irregular heterogeneous abnormal signal intensity lesion in left temporo-parietal lobe having central area of diffusion restriction and peripheral wall enhancement on post-contrast images. He underwent mini-craniotomy for abscess drainage. Pus culture revealed growth of lactococcus lactis. He was treated with ceftriaxone and remained disability-free on six month follow-up. To our knowledge, this is one of the few reports of brain abscess caused by lactococcus lactis. Key Words: Brain abscess, Lactococcus lactis, Adolescent.

Sociodemographic, Clinical Characteristics, and Outcomes of Influenza Pneumonia Patients Admitted in a Tertiary Care Hospital in Karachi, Pakistan: Findings from a Cross-sectional Study.

OBJECTIVE: To determine the sociodemographic, clinical characteristics, and outcomes of influenza pneumonia patients in tertiary care hospital, Karachi Pakistan. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital Karachi Pakistan from  January 2013 to December 2018.  Methodology: All adult patients who were older than 18 years and suspected to have viral pneumonia were included in the study. Data were abstracted on 105 patients and were entered on preformed proforma after reviewing the files of patients. RESULTS: Ninety-four (89.5%) patients were influenza positive and 15.2% (n=16) had been vaccinated. Around 92.4% (n=97), 81.9% (n=86) and 61.9% (n=65) patients had cough, fever and shortness of breath, respectively; and 63.8% (n=67), 16.2% (n=17), and 2.9% (n=3) patients had consolidation, nodules, and cavitation, respectively. Almost 91.4% (n=96) patients were given treatment and discharged home; however, 7.6% (n=8) died. Procalcitonin, creatinine, HCO3 , lactate, and bilirubin level were increased in 2nd group (mortality group) after 48 hours; however, the results were only significant for HCO3 (p = 0.035). CONCLUSION: Influenza pneumonia is very common in our population and older people are more likely to be affected by this disease. Patients can be prevented from adverse outcomes and complications, if diagnosed and treated in time. Key Words: Influenza, Clinical characteristics, Outcome, Patients.

Risk of Multiple Sclerosis in Epstein-Barr Virus Infection.

Multiple sclerosis (MS) is a chronic neuro-inflammatory, immune-mediated disorder of the central nervous system; however, less is known about its cause. It causes neurological disability in young adults, more commonly in women. Several risk factors including environmental, genetics, and infections have been identified, which contribute to the abnormal immune response. Viruses belonging to the Herpes family have been indicated as a potential risk for MS; their biological mechanisms are not known but several possibilities have been discussed. Epstein-Barr virus (EBV) is the leading and most common virus associated with MS. It is a potential oncogenic virus that hosts the B lymphocytes and has been associated with numerous cancers such as Burkitt's lymphoma, Hodgkin's lymphoma, and nasopharyngeal carcinoma. The risk of MS is low in patients who are EBV negative but increases by several folds in individuals who have a history of infectious mononucleosis (IM). Several ecological studies, co-occurring pathologies, and experimental laboratory-based research provide evidence to support the relationship between EBV and MS.

Pruritus Associated With Chronic Kidney Disease: A Comprehensive Literature Review.

The prevalence of pruritus in chronic kidney disease (CKD) patients has varied over the years, and some studies suggest the prevalence may be coming down with more effective dialysis. Chronic kidney disease-associated pruritus (CKD-aP), previously called uremic pruritus, is a distressing symptom experienced by patients with mainly advanced chronic kidney disease. CKD-aP is associated with poor quality of life, depression, anxiety, sleep disturbance, and increased mortality. The incidence of CKD-aP is decreasing given improvements in dialysis treatments, but approximately 40% of patients with end-stage renal disease experience CKD-aP. While the pathogenesis of CKD-aP is not well understood, the interaction between non-myelinated C fibers and dermal mast cells plays an important role in precipitation and sensory stimulation. Other causes of CKD-aP include metabolic abnormalities such as abnormal serum calcium, parathyroid, and phosphate levels; an imbalance in opiate receptors is also an important factor. CKD-aP usually presents as large symmetric reddened areas of skin, often at night. Managing CKD-aP is a challenge. Research in this area is difficult because most studies are not comparable given their small group samples, study designs, and lack of standardized study measures. The most commonly used treatment is a combination of narrow-band ultraviolet B phototherapy and a µ-opioid receptor antagonist such as naltrexone.

Role of Bisphosphonates in Postmenopausal Women with Osteoporosis to Prevent Future Fractures: A Literature Review.

Postmenopausal women who have osteoporosis are at increased risk of future fractures. Bisphosphonates are drugs that are used to treat osteoporosis by acting on the osteoclasts to inhibit bone resorption. Several studies have shown that bisphosphonates can maintain or even increase bone mineral density in osteoporosis patients. This review study analyzed the literature on clinical experiments with bisphosphonate therapy in postmenopausal women to determine if these drugs are efficacious in preventing future fractures. Four out of five studies found that women treated with bisphosphonates were at a decreased risk of future fractures, and six of six studies found that bisphosphonate therapy increases bone mineral density relative to placebo control. Although further work is warranted to understand the level of bone mineral density increase that is associated with fracture prevention, this study implies that bisphosphonate therapy can be used to help prevent future fractures in postmenopausal osteoporotic women. The study is significant in that it helps to underscore the efficacy of bisphosphonate therapy in postmenopausal women, and it may be generalizable to other populations with osteoporosis who are at increased risk of fractures.

A Patient of Multiple Myeloma with Absent M-spike on Serum Protein Electrophoresis and Elevated Serum-Free Light Chains: A Case Report and Literature Review.

Multiple myeloma is a neoplasm described as an abnormal growth of plasma cells that outnumbers the other normal hematopoietic cells inside the bone marrow. Patients are diagnosed at a median age of 66-77 years with 37% of those with age less than 65. Unexplained bone pain (most commonly in back and ribs), pathologic fractures, fatigue, and weight loss are common initial symptoms at presentation. Here, we report a rare presentation of multiple myeloma with normal serum protein electrophoresis but elevated serum-free light chains. The absence of monoclonal gammopathy on protein electrophoresis or normal immunofixation does not negate the diagnosis of multiple myeloma. Therefore, all the sub types of multiple myeloma need to be comprehensively studied to aid in reaching an accurate diagnosis.

Iron III isomaltose induced hypersensitivity reaction.

Iron isomaltose is considered as safe form of iron with no test dose recommended. Here, we are describing the case of a patient who experienced allergic reaction with this formulation of iron. A 35-year-old South Asian woman experienced allergic reaction, she had mild wheeze on examination of chest. She was given intranasal oxygen at 2 L/min. She was given intravenous acetaminophen 1 g for pain relief, 45.4 mg intravenous chlorphenaramine and intravenous 100 mg hydrocortisone. Within half an hour, all her symptoms improved and her hypoxia resolved. Her chest wheezing also disappeared. Iron isomaltose, although relatively safe, can cause allergic reaction. Intravenous iron can cause allergic reaction therefore it should be administered at the facility where trained staff is present so that necessary treatment can be given in case of hypersensitivity reaction.

Third Ventricular Tumors: A Comprehensive Literature Review.

Third ventricle tumors are uncommon and account for 0.6 - 0.9% of all the brain tumors. Tumors of the third ventricle are classified into primary tumors, such as colloid cysts, choroid plexus papillomas, and ependymomas, or secondary tumors, such as craniopharyngiomas, optic nerve gliomas, pineal tumors, and meningiomas. Third ventricular tumors are uncommon, and their treatment involves significant morbidity and mortality. The colloid cyst has a better surgical outcome and many approaches are available to achieve a complete cure. Choroid plexus papilloma is also a common tumor documented with its treatment majorly based on surgical resection. In addition to multiple treatment options for craniopharyngiomas, surgery is the most preferred treatment option. Ependymomas also have few treatment options, with surgical resection adopted as the first line of treatment.

CD133 Expression in Glioblastoma Multiforme: A Literature Review.

Glioblastoma, also known as glioblastoma multiforme (GBM), is the most common primary brain tumor. Extensive research has been carried out to discover the factors associated with the course and progression of GBM. CD133 is a glycoprotein antigen found in normal and malignant tissues. CD133 has been recognized as a marker for the growth of cancer cells. The association between this tissue marker and GBM is being investigated. The aim of this review was to evaluate the role of CD133 as a tumor marker for the prognosis of GBM.

Improvement of Chronic Idiopathic Urticaria With Levothyroxine: A Case Report and Review of Literature.

There is an increased association between chronic urticaria (CU) and thyroid autoantibodies. We presented a case of a patient suffering from CU and newly diagnosed Hashimoto's thyroiditis in which levothyroxine therapy completely resolved the symptoms of urticaria. A 58-year-old female with a past medical history of recurrent urticaria presented with complaints of fatigue and weight gain. Laboratory investigations showed a high thyroid stimulating hormone (TSH) level and a low free thyroxine (T4) level. She had elevated levels of antithyroid peroxidase (anti-TPO) and anti-thyroglobulin antibodies (anti-TG). She was diagnosed as a case of Hashimoto's thyroiditis and started on levothyroxine therapy. She noticed that her uncontrolled recurrent urticaria started to get better and after a few months of therapy, she stopped taking her topical ointments and antihistamines. The reason for the association between positive serological tests for thyroid autoimmunity and CU is unclear. The resolution of chronic urticaria with levothyroxine in our patient with Hashimoto's thyroiditis suggests a common underlying mechanism between the two pathologies.

Thrombotic Thrombocytopenic Purpura Associated with Dermatomyositis.

Dermatomyositis and thrombotic thrombocytopenic purpura (TTP) are both rare diseases. TTP is a blood abnormality in which blood clots form in blood vessels leading to fatal outcomes. Dermatomyositis is an inflammatory myopathy which causes a distinctive skin rash and muscle weakness. We are hereby presenting the case of a 27-year-old female who presented with characteristic skin findings on the face pathognomic of dermatomyositis and further investigation revealed that she had underlying TTP.

Comparison of Decompression Alone Versus Decompression with Fusion for Stenotic Lumbar Spine: A Systematic Review and Meta-analysis.

The first line of treatment for lumbar spinal stenosis (with or without lumbar degenerative spondylolisthesis) involves conservative options such as anti-inflammatory drugs and analgesics. Approximately, 10%-15% of patients require surgery. Surgical treatment aims to decompress the spinal canal and dural sac from degenerative bony and ligamentous overgrowth. Different studies have given conflicting results. The aim of our study is to clear the confusion by comparing two surgical techniques. This meta-analysis was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. A literature search was conducted of the Ovid Embase, Scopus, Pubmed, Ovid Medline, Google Scholar, and Cochrane library databases. A quality and risk of bias assessment was also done. The analysis was done using Revman software (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014, Copenhagen, Denmark). A total of 76 studies were extracted from the literature search and 29 studies with relevant information were shortlisted. Nine studies were included in the meta-analysis after a quality assessment and eligibility. Fusion with decompression surgery was found to be a better technique when compared to decompression alone for spinal stenosis in terms of the Oswestry Disability index and the visual analog pain scale for back and leg pain. On the basis of the meta-analysis of the recent medical literature, the authors concluded that decompression with fusion is a 3.5-times better surgical technique than decompression alone for spinal stenosis.

Amyloidosis Presenting with Macroglossia.

Macroglossia is an uncommon condition that causes cosmetic and functional disabilities. We present a case of a 67-year-old patient with the past medical history of vitamin B12 deficiencies who presented with macroglossia and was found to have amyloidosis. She had an enlarged tongue with multiple ulcerations secondary to traumatic injury from dentation along with difficulty swallowing. Laboratory workup was unremarkable apart from elevated C reactive protein (CRP) and low complement 3 (C3) levels. On the second day of admission she had gastrointestinal bleed; computed tomography (CT) scan of the abdomen with oral contrast was performed which revealed nodular thickening of the stomach suspicious for gastric malignancy. Endoscopy was postponed as there was concern that macroglossia could comprise the airway. A biopsy of the tongue was performed and histological staining was positive suggestive of the amyloidosis. We discuss here the probable underlying causes of macroglossia and amyloidosis.

Evaluation of quality of warfarin therapy by assessing patient's time in therapeutic range at a tertiary care hospital in Pakistan.

OBJECTIVE: To assess the time in therapeutic range in patients on warfarin anti-coagulation therapy. METHODS: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients having undergone anti-coagulation with warfarin from January 2013 to April 2015. To determine the mean time in therapeutic range, Rosendaal method was used. Association of time in therapeutic range with the composite outcome, bleeding and thromboembolic events was also assessed. Percentage of patients with time in therapeutic range <60% was calculated. RESULTS: There were 92 patients whose median time in therapeutic range was 34.9% (interquartile range: 20.0- 55.7). Overall, 71(77.2%) patients had time in therapeutic range below 60% which had statistically significant correlation with the composite outcome (p<0.05). Number of comorbids was significant in predicting time in therapeutic range and patients with time in therapeutic range< 60% (p<0.05). CONCLUSION: Subjects had poor anti-coagulation quality. It might be prudent to move towards novel oral anticoagulant drugsas the first choice for therapeutic anti-coagulation.

Pheochromocytoma Secreting Large Quantities of Both Epinephrine and Norepinephrine Presenting with Episodes of Hypotension and Severe Electrolyte Imbalance.

Pheochromocytoma is a rare tumor usually arising from the adrenal medulla (strictly speaking, those arising outside the adrenal gland are called paragangliomas). We report a case of pheochromocytoma presenting as orthostatic hypotension and electrolyte imbalance. A 51-year-old woman was admitted because of vomiting and chest pain. She had fluctuating blood pressure (BP) with episodes of orthostatic hypotension. Computed tomography pulmonary angiogram was performed to rule out pulmonary embolism; it showed a clear chest, but an incidental right suprarenal mass. The biochemical analysis supports the diagnosis of pheochromocytoma. Her electrolyte panel revealed persistently low potassium, calcium, and magnesium levels despite aggressive replacement. We speculated that hypotension was mainly due to vasodilatation caused by excess plasma epinephrine and prescribed doxazosin and a nonselective beta-adrenergic blocker which stabilized BP. The right adrenal tumor excised, and postoperatively she remained hemodynamically stable with no hypotensive episode. Laboratory data taken six weeks after surgery show normal 24-hour urine metanephrine and normetanephrine and normal serum magnesium and calcium levels. This case report highlights the variable presentation of pheochromocytoma. We also discuss the probable mechanisms of electrolyte imbalance in our case.

A Patient with Artifactually Low Serum High Density Lipoprotein Cholesterol Due to Waldenstrom Macroglobulinemia.

When very low or undetectable high density lipoprotein (HDL)-cholesterol (HDL-C) is encountered in clinical practice, a paraproteinemia should be suspected in the absence of genetic or more obvious secondary causes. We reported a case of artifactually low HDL-C in a 68-year-old man with a past medical history of vitamin B12 deficiency. Lipid panel showed total cholesterol (TC) 144 mg/dl, triglycerides (TG) 79 mg/dl, HDL-C 5 mg/dl, and low density lipoprotein (LDL) 123 mg/dl. HDL-C, which was determined three years prior to this presentation was found normal. The patient was prescribed extended release nicotinic acid. Further workup performed showed the ratio of APO B/APO A1 0.36 and direct LDL 28 mg/dl. In the absence of genetic or more obvious secondary causes, we hypothesized that low HDL-C in this patient was due to paraprotein interference in vitro with the liquid homogenous HDL assay. Serum protein electrophoresis demonstrated normal IgG and IgA and an abnormally high IgM at 3510 mg/dl (57-266). A bone marrow biopsy revealed Waldenstrom macroglobulinemia. A diagnostic workup for an isolated low HDL-C unmasking the diagnosis of Waldenstrom macroglobulinemia has been rarely reported. Care must be taken when using the homogeneous method for direct measurement of HDL-C as artifactually undetectable HDL-C might result in the mismanagement of patients with paraproteinemia.

Generalized Edema Caused by Albiglutide: A Case Report.

Albiglutide is a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist administered by weekly injection. Albiglutide-treated patients experience incidences of adverse effects, including cardiovascular, renal, and gastrointestinal symptoms and injection-site reactions. We report the first case of generalized edema induced by albiglutide. We present a 35-year-old female with type-2 diabetes. She developed generalized edema after the start of albiglutide. Her physical examination and all the laboratory tests, including thyroid function tests, albumin level test, and renal function test were unremarkable, and did not explain her generalized edema. Later on, her albiglutide was discontinued, which lead to the resolution of her edema. We conclude that her generalized edema could be due to a possible side effect of albiglutide.

Acute Liver Injury Induced by Sitagliptin: Report of Two Cases and Review of Literature.

We present two cases of acute liver injury associated with sitagliptin. The first case was a 58-year-old male with a history of poorly controlled type 2 diabetes mellitus and hyperlipidemia. Sitagliptin was added for better control of diabetes. After initiation of sitagliptin, the patient's serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased gradually over a period of six months. The second case was a 44-year-old female with type 2 diabetes mellitus, and she experienced a more than ten-fold elevation in ALT and AST levels after starting sitagliptin therapy. Both patients did not have any history of alcohol abuse, acetaminophen use, or chronic liver disease. In the literature review, the reported magnitude of liver enzyme derangement with sitagliptin is generally mild and transient (two-fold upper limit of normal). We believed that the acute derangement of ALT and AST in our patients was due to sitagliptin since the ALT and AST normalized shortly after sitagliptin was discontinued and remained at baseline after resuming all other medications. Further research is needed to understand the mechanism of dipeptidyl peptidase 4 (DPP-4) inhibitors associated liver injury.

Graves' Disease Presenting as Painful Goiter: A Case Report and Review of the Literature.

A painful and tender thyroid gland is a rare phenomenon in Graves' disease. We present a case of 31-years-old Guyanese female who was admitted to the hospital with complaints of neck pain for the past few days. She also reported increase appetite for a few weeks; she did not have palpitations, heat intolerance, or muscle weakness. The presence of hyperthyroidism with elevated TSI suggested that the patient had Graves' disease. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were within normal limit, thus the diagnosis of thyroiditis was effectively ruled out. This is a rare case of a painful and tender thyroid gland in Graves' disease without the evidence of sub-acute thyroiditis.

Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto's Thyroiditis: A Case Report and Review of Literature.

Hashitoxicosis is the initial hyperthyroid phase of patients with Hashimoto's thyroiditis and, usually, this phase lasts for one to two months. We report a case of a 21-year-old male who had Hashitoxicosis of two years duration before converting to Hashimoto's hypothyroidism. He initially presented with complaints of increased appetite, heat intolerance, fatigue, and sweating. On a physical exam, he had mild exophthalmos with lid lag and a fine tremor in the hands. Thyroid function tests also confirmed that the patient had hyperthyroidism. Thyroglobulin antibody and thyroid peroxidase antibody were both positive. He also had mildly elevated thyroid-stimulating immunoglobulin (TSI) but decreased radioactive iodine uptake scan. Based on the clinical presentation and biochemical test, a diagnosis of Hashitoxicosis was made. This hyperthyroid phase lasted for a period of two years. The patient eventually developed hypothyroidism suggesting that Hashimoto's thyroiditis was the most likely diagnosis. He was started on levothyroxine replacement therapy and remained euthyroid on levothyroxine since that day. The initial presentation mimicked Grave's disease, but with decreased radioiodine uptake, despite the high TSI level, leading us to treat him medically and not with radioactive iodine therapy. The patient was thus spared unnecessary radioactive iodine therapy (RAI) therapy.