Isolated Splenic Cold Abscesses in an Immunocompetent Individual.

Tubercular splenic abscess is extremely rare, but are reported commonly in HIV-positive and immunocompromised patients along with miliary or disseminated tuberculosis. Isolated tubercular splenic abscess in an immunocompetent individual is rarely reported. Here we present a case of a young, immunocompetent male with isolated splenic cold abscesses, who was diagnosed with splenic tuberculosis and managed successfully with percutaneous drainage and anti-tubercular therapy alone.

Methemoglobinemia in a Case of Paint Thinner Intoxication, Treated Successfully with Vitamin C.

BACKGROUND: Methemoglobin (MetHb) is an oxidized form of hemoglobin. It is a poor transporter of oxygen and is unable to deliver oxygen to the tissue. Globally, drug & toxin induced methemoglobinemia is more common as compared with the congenital form. Methemoglobinemia caused by paint thinner intoxication is rare. Methylene blue is well established as the first-line therapy for severe methemoglobinemia. CASE REPORT: A 25-year old man was brought to the Emergency Department after accidental consumption of paint thinner. On clinical examination, he had cyanosis and there were discrepancies in his pulse oximetry and arterial blood gas (ABG) analysis results. With this clue and supporting laboratory investigations, the diagnosis of toxin-induced methemoglobinemia was made. Due to the unavailability of methylene blue, alternative treatment with high-dose vitamin C was attempted, to which the patient responded. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The role of vitamin C in the treatment of methemoglobinemia has not been well established, with only a few published case reports. This patient had severe methemoglobinemia, with MetHb of 46.4%, which responded dramatically to vitamin C therapy, with no side effects. This case shows that high-dose vitamin C is safe and has the potential to be an effective alternative for the treatment of severe methemoglobinemia. In the presence of cyanosis, mismatch of pulse-oximetry and ABG-analysis are the key for the physician to suspect methemoglobinemia.

Fanconi Syndrome: A Rare Initial Presentation of Acute Lymphoblastic Leukemia.

A-14-year old boy, presented with a short history of excessive thirst and increased urine output. Clinical examination showed pallor, generalized lymphadenopathy and hepatosplenomegaly. For evaluation of his polyuric state he underwent routine laboratory investigations, including renal function test, acid-base studies, urine analysis. Blood tests suggested hypokalemia, hypouricemia, hypocalcemia and hyperchloremia with normal liver and kidney function tests. The arterial blood gas analysis was suggestive of normal anion gap metabolic acidosis. Urine analysis was suggestive of hyperuricosuria, hypercalciuria and glycosuria with a positive urine anion gap. His hemogram showed pancytopenia with differential count showing 88% blasts. Bone marrow examination and flowcytometry confirmed the diagnosis of B cell acute lymphoblastic leukemia. Hence this case was atypical and very interesting in the sense that the Fanconi syndrome is very rare to be an initial presenting feature of acute lymphoblastic leukemia. The patient was started on oral as well intravenous supplementation with potassium, bicarbonate, calcium and phosphorus. Simultaneously, as per the modified BFM -90 protocol (four drug based regimen-Prednisolone, vincristine, daunorubicin, cyclophosphamide along with l-asparaginase), he was started on induction protocol. By the end of 3rd week of induction therapy, his urine output started normalizing and finally settled at the end of induction therapy. At present he is in the maintenance phase of chemotherapy.

All-Trans-Retinoic-Acid Unmasking Hypercalcemia of Hyperparathyroidism.

We present a patient of acute promyelocytic leukaemia managed with all-trans-retinoic-acid and arsenic trioxide who developed hypercalcemia with target organ damage. The patient also was simultaneously discovered to be symptomatic from hyperparathyroidism, which was unmasked after ATRA administration. Patient was successfully managed without any interruption of ATRA therapy and parathyroidectomy. We discuss the mechanisms of ATRA in causing hypercalcemia and its possible role in index case in unmasking hyperparathyroidism. Present case refutes Occam's razor and emphasise that known adverse effects shouldn't withhold clinicians from working up for other common causes for a given condition.

"Unusual Cause Of Tophi With Renal Thrombotic Microangiopathy".

Chronic neutrophilic leukemia (CNL) is a rare entity amongst myeloproliferative neoplasms (MPNs). The classical presentation of CNL is with splenomegaly, mature neutrophilic leucocytosis and hyperuricemia. We herein report a case who presented with symptoms of acute gouty arthritis. Physical examination showed typical red, tender tophi in the right hand, right foot and both pinnae suggesting an acute episode of gout. During evaluation, moderate splenomegaly, mature neutrophilia, hyperuricemia and sub-nephrotic range range proteinuria were noted. Bone marrow examination and kidney biopsy was done. Final diagnosis of CNL with acute gouty arthritis and chronic renal thrombotic microangiopathy (TMA) was made. Although hyperuricemia is a common finding in MPNs but presentation of our case with symptoms of acute tophi and chronic TMA is atypical.

A Rare Case of Hemorrhagic Cystitis in Allogeneic Hematopoietic Stem Cell Transplant Patient.

Post bone marrow transplant patients are susceptible to atypical infections, especially viral pathogens. The risk increases many folds in cases of allogeneic transplantation, which also receive GVHD prophylaxis. Viral pathogens like cytomegalovirus and herpes are the common ones encountered during follow-up period. However, in recent times there have been reports of a variety of disease manifestations of rare viruses like polyoma virus and adenovirus. These viral infections may play a crucial role in morbidity and mortality in immunocompromised patients. We hereby elaborate the follow-up course of a 36-year-old post allogeneic transplant patient of acute myeloid leukemia who developed adenovirus related haemorrhagic cystitis. Treatment with oral ribavirin lead to dramatic improvement in symptomatology within a week. This cases re-emphasizes the fact that after ruling out the commoner pathogens, it's of utmost importance to strongly consider the atypical pathogens in such cases.

Efficacy of tranexamic acid in haemoptysis: A randomized, controlled pilot study.

BACK GROUND: Haemoptysis is a life threatening condition irrespective of aetiology. Tranexamic acid (TA), a potent anti-fibrinolytic agent, has been shown to control bleeding, decrease transfusion requirement in knee & hip arthroplasty, coronary artery bypass grafting and heavy menstrual bleeding. TA also has mortality benefit in bleeding from surgical and trauma patients. But the studies, regarding efficacy and safety of TA in controlling haemoptysis are conflicting. METHOD: In this single blinded, prospective study, total 66 patients with sub-massive haemoptysis were randomized into treatment (T) and placebo control (C) groups. Group-T received intravenous (IV) TA in a loading dose of 1 g, followed by 1 g TA over 8 h infusion and group-C received IV 0.9% normal saline. The severity of haemoptysis was assessed by quantity, frequency and visual analogue scale (VAS) score. RESULTS: On day 2, frequency, quantity and VAS score of haemoptysis were 2.23 ± 2.11/day, 34.19 ± 67.0 ml and 14.72 ± 15.7 respectively in Group-T and 2.29 ± 2.0/day, 90.4 ± 79.0 ml and 31.33 ± 22.12 respectively in group-C. In group-T 16.27% patients needed intervention as compared to 38.1% in group-C (p 0.053). The mean blood transfusion (1.58 ± 0.88 & 1.67 ± 0.669 units) and hospital stay (4.14 ± 3.18 & 5.48 ± 3.26 days) was also lower in group-T as compared to group-C. Group-T had better outcomes as compared to group-C, but statistically significant only for VAS score (p 0.001). During study no adverse event of the drug was noted. CONCLUSION: TA decreases severity of haemoptysis and can be used as a bridging therapy in acute haemoptysis before definitive intervention can be under taken.

Naphthalene ball poisoning: a rare cause of acquired methaemoglobinaemia.

A 15-year-old boy presented to emergency services with accidental naphthalene ball ingestion. Following consumption he developed methaemoglobinaemia, massive intravascular haemolysis and acute kidney injury. He had no history suggestive of congenital haemoglobin M disease. Development of severe methaemoglobinaemia and intravascular haemolysis is quite unusual after consumption of a single ball of naphthalene. The patient was managed with ascorbic acid and intravenous N-acetyl cysteine. He also required haemodialysis for acute kidney injury that developed secondary to pigment nephropathy.

Contrast-enhanced fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography in mediastinal T-cell lymphoma with superior vena cava syndrome.

Positron emission tomography-computed tomography (PET/CT) is a routine investigation for the staging of lymphomas. Contrast-enhanced computed tomography is mandatory whenever parenchymal lesions, especially in the liver and spleen are suspected. We report a rare case of primary mediastinal T-cell lymphoma evaluated with contrast-enhanced PET/CT that showed features of superior vena cava syndrome.

Intra-cardiac thrombus in antiphospholipid antibody syndrome: An unusual cause of fever of unknown origin with review of literature.

Classically, antiphospholipid antibody syndrome (APS) presents with recurrent episodes of vascular thrombosis and abortions. For APS to present as fever of unknown origin (FUO) is a rare phenomenon. We present an interesting case of FUO who on workup was found to have primary APS with right atrial thrombus and chronic pulmonary thromboembolism (PTE). Fever resolved completely with anticoagulation therapy and surgical removal of the intra-cardiac thrombus. Although rare, APS should be considered in any case of FUO with prolonged activated partial thromboplastin time and/or thrombocytopenia. We also take this opportunity to briefly review 28 cases of APS with intra-cardiac thrombus reported to date in the medical literature. .