A study of dengue encephalitis with laboratory and clinical parameters in Tertiary Center of North India.

INTRODUCTION: With expanding clinical spectrum of dengue fever, encephalitis has been documented with increasing frequency. The aim of this study was to investigate the incidence, predictors and prognostic factors of dengue encephalitis (DE) in the setting of dengue viruses (DENV) infection. MATERIALS AND METHODS: A hospital-based prospective cohort study was carried out, which included laboratory confirmed dengue positive cases. All dengue cases were categorized into nonencephalitis or encephalitis group. We estimated DE incidence and analyzed clinical, laboratory and neuroimaging data on admission, discharge and follow-up for 3 months to assess its predictors and prognostic factors. RESULTS: Out of the enrolled 540 confirmed dengue cases, 27 patients had DE, representing 5% incidence. Two third of the DE patients were 20 years of age or younger, with male preponderance (81.5%). Fever, headache, and altered sensorium were present in >90% on admission. Significant predictors of encephalitis were mean body temperature during fever (P < 0.001), headache (P = 0.015), secondary dengue (P = 0.005), dengue hemorrhagic fever (P < 0.001), elevated hematocrit (P < 0.001), liver function test derangement (P < 0.05), and low platelet count (P = 0.006). Poor outcome factors for DE patients were prolonged duration of fever (P < 0.001), seizure (P = 0.002), and cerebrospinal fluid (CSF) DENV positivity (P = 0.049). One third patients died and the remainder of them recovered. An increasingly higher incidence rate with high mortality of DE is reported. CONCLUSION: Clinical and laboratory parameter along with DENV positivity in CSF can predict and prognosticate dengue encephalitis.

Corneal fibroma: An uncommon stromal tumor.

A 56-year-old male patient presented with a slow-growing, elevated, smooth, white corneal mass. The mass was excised by performing an alcohol-assisted keratoepitheliectomy and sent for histopathological examination. Subepithelially, closely packed spindle cells in "feather-stitched" or storiform pattern were seen. Immunohistochemically, the cells stained negatively for CD-34 and S-100 and focal positivity was seen for vimentin. Based on the morphology and immunochemical staining, a diagnosis of corneal fibroma was made. No recurrence was seen. Corneal fibroma is an exceedingly rare, benign tumor and possibly lies on the same spectrum as corneal keloid and hypertrophic cicatrix. Surgical resection is usually curative.

Tyrosine Kinase Inhibitors in the Treatment of Choroidal Metastases from Non-Small-Cell Lung Cancer: A Case Report and Review of Literature.

BACKGROUND: Choroidal metastases being the sole presenting feature of lung cancer is rare. Erlotinib, a tyrosine kinase inhibitor (TKI), is used in the treatment of lung adenocarcinoma where tumor cells exhibit epidermal growth factor receptor (EGFR) mutations. We report a case of metastatic non-small-cell lung cancer (NSCLC) with choroidal metastasis, which was the sole presenting feature and which responded to erlotinib. METHODS: We performed a retrospective case review. CASE: A 78-year-old man presented with a choroidal mass which was found to be the presenting feature of metastatic NSCLC. Our patient, a nonsmoker, had disseminated bony metastases, and therefore was advised to undergo palliative chemotherapy, which he refused. He was therefore instituted on oral erlotinib. RESULTS: Tumor cells expressing EGFR mutations are known to be susceptible to TKIs. Even though the tumor in our case showed no mutation, i.e. was classified as 'wild-type', our patient showed a dramatic response to erlotinib. At 1 year, the choroidal lesion had regressed and visual acuity had recovered. CONCLUSIONS: TKIs may be beneficial in patients with choroidal metastases from NSCLC, especially those in which an EGFR mutation is noted. Even in the absence of such mutations, choroidal metastases may show a favorable effect in response to TKIs, such as erlotinib.

Clinico-Epidemiological Profile, Pandemic Influenza A H1N1/2009 and Seasonal Influenza, August 2009-March 2013, Himachal Pradesh, India.

BACKGROUND: Novel influenza A (H1N1) virus emerged in April, 2009, spread rapidly to become pandemic by June, 2009. OBJECTIVE: To study the clinco-epidemiological profile of pH1N1and seasonal influenza (SI) from 2009 to 2013. MATERIALS AND METHODS: Retrospective, hospital-based study was done by reviewing medical records for collecting demographic and clinical profile of the study samples. RESULT: Out of 969 samples, positivity and case fatality for pH1N1 and SI was 9.39 and 20.87% vs 11.76 and 7.89%, respectively. Among pH1N1and SI, sex distribution, mean age, and age group involved were 54.95% females, 37.10 years, and 20-29 years (23.08%) vs 43.86% females, 40.32 years, and 20-29 years (22.81%), respectively. Mortality shift was observed from younger to older and healthier, 75% to comorbid, 100% from 2009-2010 to 2012-13 for pH1N1. CONCLUSION: We observed seasonal variation, cocirculation, similar clinical features, decreased virulence, and community spread with respect to pH1N1 and SI from 2009-2013.

Metastatic adenocarcinoma of the cervix presenting as a choroidal mass: A case report and review of literature of cervical metastases to the eye.

Cervical cancer is the most common cancer among females in India. Cervical cancer usually spreads by local extension and through the lymphatic drainage to the lymph nodes. Hematogenous spread, the mechanism responsible for distant metastases, is rarely seen in cervical malignancies. In this communication, we report a case of a 45-year-old woman who presented with unilateral decrease in vision of 3 months duration. She was found to have a serous retinal detachment with underlying diffuse, subretinal yellowish-cream colored infiltrates in the right eye, suspicious of choroidal metastases. Systemic evaluation showed disseminated systemic metastases arising from a primary adenocarcinoma of the cervix. In this communication, we review all the documented cases of metastases to the eye and adnexa arising from cervical cancer and their clinical characteristics. Unilateral choroidal metastasis arising from an adenocarcinoma of the cervix is extremely rare with only one previous documented case. Although uncommon, choroidal metastasis may be the presenting feature of primary cervical malignancy. Furthermore, cervical malignancy must be ruled out in women who present with orbital or choroidal metastases arising from unknown primary.

Inducible Clindamycin Resistance among Clinical Isolates of Staphylococcus aureus from Sub Himalayan Region of India.

INTRODUCTION: Clindamycin is an alternative antibiotic in the treatment of Staphylococcus aureus (S.aureus) infections, both in infections by methicillin susceptible and resistant (MSSA and MRSA) strains. The major problem of use of clindamycin for staphylococcal infections is the presence of inducible clindamycin resistance that can lead to treatment failure in such infections. AIM: To determine inducible and constitutive clindamycin resistance among clinical isolates of S. aureus in a tertiary care centre of sub Himalayan region of India. MATERIALS AND METHODS: A total of 350 isolates of S. aureus from various clinical samples were subjected to routine antibiotic sensitivity testing by Kirby Bauer disc diffusion method. Methicillin resistance was detected by cefoxitin (30µg) disc. All isolates were subjected to inducible clindamycin resistance was by Clinical Laboratory Standards Institute (CLSI) recommended D test. RESULTS: Among 350 S.aureus isolates, 82 (23.42%) were MRSA and 268 (76.57%) were MSSA. Erythromycin resistance was detected in 137 (39.14%) isolates. Erythromycin resistance in MRSA and MSSA was 71.6% and 29.36% respectively. Overall clindamycin resistance was seen in 108 (30.85%) isolates. Constitutive MSLB phenotype predominated (29.62% MRSA; 13.38% MSSA) followed by iMLSB (28.39% MRSA; 9.29% MSSA) and MS phenotypes (13.58% MRSA; 6.69%MSSA). Both inducible and constitutive clindamycin resistance was significantly higher (p=0.00001, 0.0008 respectively) in methicillin resistant strains than in methicillin susceptible strains. CONCLUSION: The present study gives a magnitude of clindamycin resistance among clinical isolates of S. aureus from this region of the country. Our study recommends routine testing of inducible clindamycin resistance at individual settings to guide optimum therapy and to avoid treatment failure.

Bilateral periorbital and cervicofacial emphysema following retinal surgery and fluid gas exchange in a case of inadvertent globe perforation.

Surgical emphysema is defined as gas or air trapped in the subcutaneous tissue plane. Here, we report a rare case of bilateral periorbital and cervicofacial subcutaneous emphysema following a vitreoretinal surgery for inadvertent globe perforation during the administration of peribulbar anesthesia. This condition, although self-resolving when restricted to the subcutaneous plane has the potential to spread into deeper tissue planes such as the retropharyngeal space. The presence of crepitus helps to distinguish it from angioneurotic edema. Ophthalmologists must be sensitive to the fact that surgical emphysema can be a very rare, but possible complication of an intraocular surgery following globe perforation.

The clinical challenges in the management of deep lymphangioma of the foot.

A 12-year-old girl presented with swelling on the lateral aspect of the left foot since early childhood, progressively increasing in size and now causing pain on walking. Pain was relieved with medication only. There was also history of a single episode of blood-tinged discharge from the swelling 3 years prior. There was no history of trauma, diabetes, or hypertension.

Acute myeloneuropathy: An uncommon presentation of Sjögren's syndrome.

Sjögren's syndrome is associated with central and peripheral nervous system involvement. The peripheral neuropathy is usually a sensory predominant neuropathy or a cranial neuropathy. Myelopathy is usually of focal, subacute, chronic or relapsing type. Acute myeloneuropathy as the predominant manifestation has not been described in the literature. We describe a middle aged woman who presented with an acute onset motor quadriparesis and bladder dysfunction. She had dryness of eyes and mouth for 8 months. Nerve conduction studies revealed motor axonal neuropathy and magnetic resonance imaging of spinal cord showed T2 hyperintensities involving entire cord. Mild perineural fibrosis, focal foamy changes in endoneurium and lymphocytic infiltration were seen in sural nerve biopsy specimen. Patient improved clinically after intravenous methylprednisolone therapy.

Pure motor monoparesis: solitary cysticercus granuloma.

Solitary cysticercus granuloma (SCG) is the most common form of neurocysticercosis in India and usually presents with seizures. Pure motor monoparesis (PMM) due to cerebral cysticercus lesions has been rarely reported and it has not been seen with SCG. We describe a young girl with SCG who presented with PMM without any other neurological manifestations. The lesion was located in the Penfield homunculus area of the opposite leg. The patient was treated with steroids and antihelminthic drugs. She responded well to the treatment.

Thyroid associated orbitopathy.

Thyroid-associated orbitopathy (TAO) is a self-limiting auto-immune condition usually associated with Grave's disease. It is characterised by ocular pain, eyelid swelling, chemosis, proptosis and keratopathy. As the mechanism for ophthamoplegia and optic neuropathy is the orbital swelling leading to mechanical restriction of ocular muscles and compression of optic nerve, one expects proptosis rather than ptosis in TAO. We describe a case of a young adult woman who presented with acute onset restriction of movement along with partial ptosis and severe diminution of vision in left eye. The MRI of orbit revealed significant swelling of recti along with signal alteration consistent with TAO. The radio-isotope thyroid scan revealed thyroiditis, and thyroid peroxidase (TPO) antibody was significantly high; hence, the diagnosis of Hashimoto thyroiditis was considered. A course of intravenous methylprednisolone followed by oral steroid was administered, which produced marked improvement in vision and extraocular movement.

Orbital cysticercosis: A case report.

A 22 years old male presented to us with a history of lid swelling and chemosis of conjunctiva since 2 days. The patient had a history of convulsions 4 days back and 2 months back. The patient had undergone a CT scan which showed granulomas in temporal and parietal lobes. The patient was started on Anti tuberculosis treatment by the Physician. The Patient underwent USG B scan which revealed cysticercosis cyst in the anterior orbit inferiorly .The patient was treated with albendazole and wysolone for a month. The patient was reviewed after 1 month .The lesion resolved with the treatment both clinically and on USG.

Gallbladder agenesis with common bile duct stone--a rare case with a brief review of the literature.

We present herein the case of a 45-year-old female who presented with obstructive jaundice and was diagnosed as agenesis of the gallbladder with choledocholithiasis. We discuss the radiological and operative features along with a brief literature review of this uncommon entity.

Two case reports of ultrasonography features in male genital tuberculosis.

Genitourinary tuberculosis is the common manifestation of extra-pulmonary tuberculosis. In the male genital tract, the epididymis followed by seminal vesicle, prostate, vas deferens and testis are commonly affected sites. Ultrasonography (USG) is the best imaging modality for the diagnosis of the diseases of male genital tract. We are presenting USG findings in two cases of male genital tuberculosis with involvement of the prostate, seminal vesicle, epididymis and vas deferens.