Hypopituitarism following poisonous viperbite.

A 28 years old male had the history of viperbite 3 years back. He has treated in a nearby rural hospital with snake venom antiserum along with other supportive therapy. He responded and discharged from hospital within a week. Three years later he had history of fever, drowsiness which progressed to unconsciousness. On examination he was found to have scanty body hairs, smooth, shiny skin with superficial oral ulcers. Serum hormone estimation confirmed the deficiency of gonadotrophins, thyrotrophin and corticotrophin while growth hormone failed to rise >3ng/ml after insulin intolerance test. MRI brain revealed loss of pituitary mass with positive infundibular sign and filling of sella with cerebrospinal fluid. He was managed with hormone replacement therapy and recovered gradually.

Inherited dysfibrinogenaemia presenting with portal vein thrombosis.

A 15 years old female presented with recurrent episodes of gum bleeding, easy bruisibility and recurrent soft tissue haematoma following trivial trauma since childhood. Subsequently the patient developed features of extrahepatic portal vein obstruction due to formation of thrombus. Defective fibrinogen structure due to underlying inherited dysfibrinogenaemia led to the manifestations of both bleeding due to coagulation failure and thrombosis due to failure of abnormal fibrin to get lysed.

Micro-albuminuria: a predictor of short-term mortality in acute ischaemic stroke.

We studied 89 non-diabetic patients of acute ischaemic stroke, confirmed by imaging, admitted within 24 hours of onset, to investigate the prevalence and significance of micro-albuminuria (MA) as a predictor of in-hospital mortality. Two control groups consisted of 70 patients with non-stroke chronic neurological diseases and 60 age- and sex- matched healthy individuals. Spot urinary albumin-to-creatinine ratio was measured in first morning sample on days 1, 4 and/or 7. Functional status was assessed daily for 7 days by National Institute of Health Stroke Scale (NIHSS). Outcome data were recorded for 14 days. MA was found in 61.79% of acute ischaemic stroke patients on day 1 compared to 13% in non-stroke neurological patients and 7% of healthy controls. Patients with MA were older and had a higher systolic blood pressure. The 14-day disease-specific mortality was higher in patients with MA (25.45%) compared to patients without it (5.88%). High day 1 MA (>100 microg/mg) and rising or static value from day 1 to day 4 or day 7 correlated with statistically more chance of death. Increasing MA had a positive correlation with higher NIHSS score. Thus, MA was found to be a reliable predictor of shortterm in-hospital mortality in acute ischaemic stroke.

Study of biochemical parameters of ascitic fluid in exudative ascites with special reference to tuberculous peritonitis.

In an attempt to differentiate between three important but clinically similar conditions of exudative ascites like tuberculous peritonitis, spontaneous bacterial peritonitis (SBP) and malignant ascites, we evaluated the biochemical parameters of ascitic fluid as a diagnostic aid. The serum ascitic albumin gradient (SAAG), lactate dehydrogenase (LDH), pH, adenosine deaminase(ADA), carcino-embryonic antigen (CEA) and carbohydrate antigen (CA-125) levels were measured in 36 patients with tuberculous peritonitis, 30 patients with SBP and 30 patients with ascites due to malignant disorders. The LDH level was significantly lower in tuberculous peritonitis patients than in malignant and SBP groups. A value of < 110 U/l gave the assay a sensitivity of 94% and a specificity of 93%, positive predictive value of 89% and negative predictive value of 96% for tuberculous peritonitis. The ADA activity was significantly higher in tuberculous peritonitis group than in the other two groups. A cut off value > 33 U/l gave the ADA test a sensitivity of 89%, specificity of 100%, positive predictive value of 100 % and a negative predictive value of 94% for tuberculosis. A pH value of <7.26 with high SAAG (>11 g/l) predicted SBP with reasonable accuracy. Elevated ascitic fluid CEA (>2 ng/ml) and CA - 125(> 35 U/l) was found exclusively in cases of malignant ascites with a single case of tuberculous peritonitis showing CA-125 value > 35 U/l. All these tests are rapid, non-invasive, and easily reproducible and offer good predictive accuracy which is comparable to that of more invasive procedures like peritoneoscopy and biopsy.

Adult polycystic liver disease presenting as portal hypertension.

Autosomal dominant polycystic liver disease is a systemic hereditary disorder associated with cyst formation in the ductal organs such as the kidney and liver. Multiple massive cysts are typically found in multiparous women. Portal hypertension as a presenting manifestation is very rare but may be caused by associated hepatic fibrosis or massive hepatic replacement of liver by the cysts. Two cases of adult polycystic liver disease, one in uniparous female and another in a 45-year-old male, both presenting with portal hypertension and without any demonstrable fibrosis in the liver, are reported here.

An unusual presentation of tuberculous lymphadenitis.

A 43 years male presented with recurrent epistaxis and had generalised lymphadenopathy on examination. No haematological disorder could be established even after bone marrow aspiration and biopsy but the patient was found to have tuberculosis of the lymph node on histopathology, with severe thrombocytopenia in the peripheral blood and increased platelet precursor in the marrow suggesting peripheral platelet destruction. Anti-tuberculous therapy was started but the patient died due to subarachnoid haemorrhage.