Drug-Induced Atypical Lipodystrophy.

We describe a case of an Asian-Indian female patient who presented to us with abnormal fat accumulations in the torso and upper arms following indiscriminate use of corticosteroid and anabolic steroids for about 7 years. Despite prolonged steroid use, the patient did not display cushingoid phenotype or metabolic decompensation. Bone density, echocardiography, and ultrasonogram of the liver were also normal with no evidence of excess pericardial fat, hepatic steatosis, or peliosis hepatis. Concurrent use of anabolic androgen is thought to be protective against the ill effects of steroids, especially on the muscle and bone. This phenomenon has been observed in children and adolescents with Cushing syndrome where the adrenal androgen excess and increased physical activity have shown to reasonably reduce protein catabolism and help in preserving muscle and bone mass. The patient was withdrawn from the drugs and was put on replacement hydrocortisone that was gradually tapered over the next few weeks and planned for surgical correction. This case highlights the fact that medical providers should be aware that a combination of anabolic steroids and glucocorticoids are still used for weight-building purposes, and these patients may present with atypical signs/symptoms as a result of this combination of drugs.

Association of Variant rs7903146(c/t) Single Nucleotide Polymorphism of Transcription Factor 7-like 2 Gene with Newly Detected Hyperglycemia in Pregnancy.

Background: Transcription factor 7-like 2 (TCF7L2) gene has a significant role in hyperglycemia in pregnancy (HIP) risk. The current study was planned with the aim to evaluate the association of single nucleotide polymorphism (SNP) rs7903146 in patients of newly detected HIP among Indian population of northern region. Methods: This study was an observational case control study done among newly detected HIP (The World Health Organization (WHO) criteria, 2013) and healthy pregnant females without diabetes. Participants from both the group were genotyped for rs7903146 (C/T) variant of TCF7L2 gene using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Results: A total of 71 cases of newly detected HIP were included in the study, out of which 25 (35.2%) of them were of first-time detected diabetes mellitus in pregnancy (DIP) and 46 (64.7%) were of gestational diabetes (GDM) and 100 were pregnant females without diabetes in third trimester were enrolled as controls. Average age of participants in the case group was 28.7 ± 4.0 years and the control group were 26.5 ± 3.6 years (P value 0.09). The wild homozygous CC genotype, heterozygous CT genotype and homozygous TT genotype were present in 39.4%, 53.5%, 7.1% of case group vs 53%, 43% and 4% of control group, respectively. No significant association of rs7903146(C/T) SNP of TCF7L2 gene in HIP (CC/CT, CC/TT P value 0.15, 0.38, respectively) in our population was found. There was no significant difference in the distribution of genotypes between DIP and GDM. Conclusion: This study shows no evidence of association of rs7903146(C/T) SNP of TCF7L2 gene with newly detected HIP in our population.

Early Clinical Suspicion and Early Use of Doxycycline Reduces Scrub Typhus Associated Complications.

BACKGROUND: Scrub typhus has emerged as an important cause of febrile illness in this Himalayan region of the country. However, it is under considered in the differential diagnoses of febrile illnesses and is not treated and thus, patients often land up with complications in this tertiary care hospital. METHODOLOGY: It was a retrospective observational study done in department of Medicine from august 2013 to October 2013. All the patients more than or equal to 18 yrs of age admitted during this period with scrub typhus were analysed and their outcome followed. S. ELISA was used to detect scrub typhus. RESULTS: Total of 106 patients were observed out of which only 10 patients had received anti scrub antibiotics (doxycycline or azithromycin) prior to admission. Seven patients died (6.6%) and none had received anti scrub antibiotics prior to hospitalisation and presented late with average duration of illness of 9.2 days and had more severe form of complications at presentation.Those patients who had received prior anti scrub treatment had fewer and mild complications and none died among that group. CONCLUSION: Doxycycline or azithromycin (pregnancy or in child <8 years) should be included in the initial empirical antimicrobial therapy in febrile patients during tick season to treat scrub typhus. The goal is to begin anti-scrub therapy early to reduce the morbidity and mortality associated with this illness.

Factors for Severe Outcome in Scrub Typhus: A Hospital Based Study in Sub Himalayan Region.

Background: Scrub typhus is a re-emerging zoonotic rickettsial infection. Mortality is approximately 15% in some areas due to missed or delayed diagnosis. There had been only few studies on the markers for the severity of the disease, so this study has been planned to provide the knowledge regarding various aspects of scrub typhus in adult age group to detect early signs of severity . Methods: All the patients more than 18 years of age admitted with febrile illness with positive IgM ELISA for scrub typhus with or without eschar were included in the study. The clinical profile was observed. The predictors of mortality were explored using univariate and multivariate analysis. Results: On linear regression analysis and logistic regression analysis altered sensorium, low serum albumin, hepatic dysfunction, renal dysfunction, septic shock, MODS, ARDS, duration of fever > 7 days, day of receiving treatment > 7 days at presentation were significantly associated with high in- hospital mortality. Conclusions: Early treatment with doxycycline should be instituted at the clinical suspicion of scrub pending investigation as it is life saving. Close follow up of the patient should be done to indentify subtle signs of organ dysfunction to start early supportive treatment.

Clinical Profile and Outcome of Acute Pancreatitis: A Hospital-Based Prospective Observational Study in Subhimalayan State.

Background: Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. We aimed to determine the incidence, etiology, severity, and outcome of AP. Materials and Methods: This was an observational prospective study done on 123 patients with AP during one year period in IGMC, Hospital Shimla. Detailed Clinical history was recorded and examination and lab investigations were done. Severity of AP was assessed using modified Atlanta classification. Results: In this study, 123 patients were included- 89 men (72.35%) and 34 women (27.65%). Median age of presentation was 42 years. The most common presentation was abdominal pain followed by vomiting. The major etiological groups were as follows: alcohol 73 cases (59.3%), gallstones 40, (35.6%); postendoscopic retrograde cholangio-pancreatography 1 (0.8%), hypertriglyceridemia 3 (2.9%), autoimmune 1 (0.8%) and idiopathic 5 cases (4%). Alcohol was the most common cause of AP and followed by gallstone. Mortality was seen in 7(5.7%) patients. Out of seven patients who died in hospital, 5(71.42%) had severe pancreatitis and 2(28.57%) patients had moderately severe pancreatitis. When compared, patients with BMI ≥25, HCT≥44% and CRP ≥150mg/l had an increased risk of developing a severe form of AP. Conclusions: Alcohol and gallstones were the most common etiology of AP. HCT, CRP and BMI done at admission are useful predictors of severe pancreatitis.

Hemophagocytic Lymphohistiocytosis Secondary to Acute Hepatitis E Infection: A Rare Association.

Viral infections are commonest cause of secondar y hemophagoc ytic lymphohistiocytosis (HLH) and Ebstein Bar Virus is associated with majority of cases. We report a rare case of HLH associated with acute hepatitis E virus infection.

Scrub Typhus - The Most Common Cause of Febrile Jaundice in a Tertiary Care Hospital of Himalayan State.

BACKGROUND: Most common cause of jaundice in south east Asia is of infective etiology. Combination of fever with jaundice can cause diagnostic problem as this duo is present in many infective diseases. Timely diagnosis by simple laboratory investigations can save a lot of time and prevent morbidity and mortality. Our main aim was to determine the most common etiology of infectious jaundice in a tertiary care hospital of Himalayan state and to study their clinical profile. METHODOLOGY: This was a prospective observational study done in one year. All the patients more than 18 years of age presenting with jaundice with bilirubin >1.5mg/dl were taken. The clinical profile was observed and investigations for etiology were done. RESULTS: Total number of patients studied were 170. Maximum number of patients were 50 (39.4%) in age group less than 30 years and females outnumbered males with 1.8:1 ratio (64.7% v/s 35.3%). Fever was the most common presenting complaint in 127 (74.7%) patients and most common etiology was scrub typhus with 103 patients (60.6%) followed by hepatitis E in 36 patients (21.2%) and leptospirosis in 9 patients (5.3%). CONCLUSIONS: Scrub typhus is the commonest cause of febrile jaundice in Himachal Pradesh. The general physicians should be sensitized for the early diagnosis to reduce mortality.

Diabetes Drug Prescription Pattern and Awareness Among Health Care Providers in Sub-Himalayan Region of India: A Population Based Study.

BACKGROUND: To determine the pattern of diabetic drug prescription and awareness about diabetes among primary health providers in the rural areas of Himachal Pradesh situated in the western Himalayas at an elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level. METHODS AND MATERIAL: Study was conducted in 20 rural areas of Himachal Pradesh, located 50 to 400 Km from state capital, at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults were surveyed through 31 diabetic camps. Detailed history, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: 894 diabetic patients were included in the study (59.83% male) with the mean age of 52.94±6.78 years. Two in three patients were on oral hypoglycemic agents (OHAs), and one in three on alternative approaches for diabetes control. Among OHAs, sulphonylureas (SU) were the most commonly prescribed oral agents in 76.09% of patients followed by metformin in 23.87%. Glibenclamide was the most commonly prescribed SU in 44.60%. Amlodipine and atenolol was the commonest anti-hypertensive drug prescribed in 77.85% either in combination or as individual drug. Only 10.59% were on lipid lowering therapy. For primary care providers glycemic target was the mainstay of diabetes treatment with little emphasis on blood pressure control and no emphasis on lipid reduction. CONCLUSIONS: Sulphonylureas were the commonest anti-diabetic drug prescribed by the primary care providers followed by metformin. Insulin was prescribed to 2.23% only. Combination of amlodipine and atenolol was the commonest anti-hypertensive drugs prescribed and only 10% of patients were prescribed statin.

Prevalence of Cardiovascular Risk Factors among Diabetic Population and Awareness of Diabetes among Diabetic Patients: A Population Based Himalayan Study.

BACKGROUND: To determine the prevalence of modifiable cardiovascular risk factors among adults with diabetes in the remote Himalayan areas, at elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level, in the Indian state of Himachal Pradesh. MATERIAL AND METHODS: Study was conducted in 21 rural areas of Himachal Pradesh situated at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults (>18years) were surveyed, through 32 diabetic camps. The date and place of the camp was decided one month in advance and advertised. Detailed history including smoking status, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: Total 909 eligible adult diabetics were surveyed (59.73% male) with a mean duration of disease 38.14±4.56 months.35.54% adults were smoker and 67.55% were either overweight or obese 54.04% males and 77.53% females had waist circumference above Indian standards. 78.35% had A1C >7% and 61.50% had blood pressure measurements above target (>140/80mmhg). 56.74% had elevated LDL and only 6.32% had all blood glucose, blood pressure and cholesterol at recommended levels. CONCLUSIONS: High prevalence of modifiable cardiovascular risk factors in addition to uncontrolled blood glucose is widespread, placing diabetics at higher risk for cardiovascular disease. Improved disease management system in addition to public awareness campaign is needed for people with diabetes in this region of the country.

Insulin Myths and Impact of Round-Tree Group Education Programme on Acceptance of Insulin in Persons with Diabetes: A Study from the Himalayas.

BACKGROUND: Insulin is the natural treatment of diabetes mellitus. It is the oldest, most potent and natural therapy of diabetes mellitus; if used timely and in appropriate doses. Most diabetic patients either do not receive it or do not receive it timely. This study was conducted to assess the myths about insulin therapy among type 2 diabetes patients and the impact of open-air discussion on its acceptance in the rural areas of Himachal Pradesh. METHODOLOGY: Study was conducted in 21 rural areas of the state. 909 non-pregnant diabetic adults were surveyed through 32 diabetes camps organized between April 2008 to August 2013. The date and place of camp decided one month in advance. Group education programmes, including 'lectures' and "round tree" discussions conducted. RESULTS: The mean age was 53.94 ± 6.87 years (27-84 years). 49.91 % (279) were eligible for insulin therapy (59.49% male) based on A1C >9 %, and/or >7% despite maximum doses of oral hypoglycemic drugs. Only 7.88% (13males and 9 females) agreed to take insulin at first suggestion. Economic status and educational standard inversely related to the acceptance of insulin. After this educational activity, 34.76% (67 males and 30 females) more patients agreed for insulin therapy, increasing total number to 42.65%. CONCLUSION: This study reveals the myths regarding insulin and suggests that community-based group education programs help increase in acceptance of insulin. Sensitization of local health care providers is necessary to ensure persistence with insulin therapy.

High Prevalence of Hypovitaminosis D in Patients Presenting with Proximal Muscle Weakness: A Sub-Himalayan Study.

BACKGROUND: Hypovitaminosis D has emerged as a major public health problem and 25-50% of patients encountered in clinical practice are deficient in vitamin D. This study was conducted to estimate the prevalence of hypovitaminosis D among patients presenting with proximal muscle weakness. STUDY DESIGN: It was a cross-sectional study done on patients ≥18 years presenting in outdoor clinic from May 2008 to April 2013, with difficulty in standing and going up stairs/ diffuse musculoskeletal pains. Proximal muscle weakness due to other causes were excluded through investigations and those taking steroids and/or indigenous drugs were also excluded. Vitamin D levels measured by radioimmunoassay (RIA) in all eligible patients and individuals included in the study were those with hypovitaminosis D (<30ng/dl) and proximal muscle weakness. Patients reassessed after supplementation with vitamin D at 2 and 6 months. RESULTS: 99 patients with hypovitaminosis D associated proximal myopathy included in study. Of these 55 (55.55%) were males and 44 (44.44%) were females. Age ranged from 22 to 82 years with a mean of 52.84 ± 12.6 years. Of 99 patients, 55 (55.55%) were from the rural area and 44 (44.44%) from urban area. Mean duration of symptoms was 22.7 months (range 6-60 months). The level of 25(OH) Vitamin D ranged from 2.0 ng/dl to 35.7 ng/dl with the mean level of 13.18 ± 5.80 ng/dl (males = 12.76± 4.85ng/dl and females = 13.60±6.70ng/dl). Hypovitaminosis D was present in 98.98%. A direct relationship was found between the vitamin D levels (<10 ng/dl) and severity of weakness. Of 83 patients, who reported at the end of two and six months of treatment, 71 (85.54%) patients were able to stand-up from squatting position. CONCLUSION: Muscle weakness is common among vitamin-D deficient individuals. Our study indicates that more focus should be on muscle symptoms in at risk population groups. The vitamin D deficiency related myopathy should not be missed due to its potential reversibility with vitamin D supplementation.

Sheehan's Syndrome-The Most Common Cause of Panhypopituitarism at Moderate Altitude: A Sub-Himalayan Study.

Background: Panhypopituitarism is a rare disorder with varied clinical presentation having various etiologies. Sheehan's syndrome (SS) is decreasing in frequency worldwide and is a rare cause of panhypopituitarism in developed nations. Methodology: A retrospective study done between May 2011 and May 2015 in tertiary care hospital. We reviewed the records of patients with hypopituitarism. Clinical features, hormonal profile and radiological investigations noted. Results: Total 14 patients of panhypopituitarism included with average duration of symptoms 1.93± 1.96 years. four (28.57%) were males and ten (71.43%) were females with mean age of diagnosis 37.78± 13.68 years. Sheehan's syndrome (SS) was the most common cause of panhypopituitarism in 57.14%(8 patients), followed by post surgery in 14.28% (2 patients). 80% of women had SS with a mean duration of symptoms 2.39±1.54 years. Conclusion: Sheehan's syndrome is not uncommon in developing countries, High degree of clinical suspicion is desired as clinical features are most often subtle.

Clinical Profile and Outcome of Pregnant Patients with Acute HEV Hepatitis During Water Borne Epidemic in Himachal Pradesh: A Hospital Based Study.

Background: Recent outbreak of HEV hepatitis epidemic in Himachal Pradesh in Shimla caused significant morbidity and mortality especially among pregnant patients. Overall mortality is 0.5- 4% in patients developing acute hepatic failure (ALF) and is significantly higher in pregnant patients (20%). Present study conducted to observe clinical profile and outcome in pregnant patients. Methodology: this is a retrospective observational study done on admitted pregnant and post partum patients with acute HEV hepatitis during 3 months periods. History focussing on symptoms, duration, onset, progression, co morbidities, pregnancy outcome, complications noted. Confirmation of the HEV infection was done using HEV IgM ELISA. Results: Total 26 patients observed, among which 8 were pregnant and 18 were post partum Average age of presentation was 26.11±3.7 years and average duration of hospital stay 10.46 days. 8 (30.76%) patients required ICU care Presenting complaints were similar to typical presentation in viral hepatitis. All patients were icteric at presentation and 8 (30.76%) patients had hepatic encephalopathy (HE) and 8 (30.76%) patients had ALF, 20 (76.92%) sepsis and 7(26.92%) underwent preterm labour. Out of the total 14 patients who delivered, poor fetal outcome was seen in 5 patients died during this period (15.38%). Factors responsible for in hospital mortality were altered mental status at presentation (p0.018), edema (p 0.046), HE(0.018), acute liver failure(0.018). Conclusion: HEV infection has more morbidity and mortality among pregnant females and poor fetal outcome. Mortality is high (15.38%). Altered mental status at presentation, edema, HE, ALF have significant correlation (<0.05) with the mortality.

Cushing's Disease presenting as Suicidal Depression.

A case of Cushing disease, who presented with suicidal depression as the main complaint is reported. Prompt diagnosis and early management of the underlying cause of Cushing's disease, not only relieved features of hypercortisolaemia but also remitted depression fully.

Clinical Profile of Scrub Typhus in Pregnancy in Sub-Himalayan Region.

BACKGROUND: Scrub typhus is rare in pregnancy, but it has now become an important cause of febrile illness in pregnancy in sub-Himalayan region of India. Only a few case reports have been published so far, and they show adverse maternal and fetal outcomes. No consensus has been reached till now regarding treatment. METHODOLOGY: All the pregnant patients irrespective of period of gestation admitted with febrile illness with positive IgM ELISA for scrub typhus with or without eschar were included. The clinical profile was observed using a detailed history of symptoms, travel, recreation, agricultural activities, treatment record prior to admission, and a detailed examination, and the treatment outcome was noted. Fever workup including cultures, CXR, CSF analysis, serology for scrub was done. IgM scrub typhus was done by kit method manufactured by InBios Intertational, Inc. RESULTS: We observed in total 14 pregnant patients out of which eight were in the the second trimester and six were in the third trimester. The clinical features of the disease observed for pregnant females were the same as for nonpregnant females. There was no difference in the severity of scrub typhus between pregnant and nonpregnant women. No mortality was found in these patients. On follow-up, they had normal peripartum and postpartum periods. All were treated with azithromycin 500 mg once a day for 5 days. CONCLUSION: Although rare, scrub typhus should be considered in differential diagnosis of fever in pregnant patients especially in scrub season. Azithromycin should be the drug of choice in pregnancy as it has no adverse effect on fetus and pregnancy outcome.

Clinical Profile and Complications of Scrub Typhus: Hospital-Based Study in Sub-Himalayan Region.

BACKGROUND: Scrub typhus is a documented disease in Himachal Pradesh, but there have been no clinico-epidemiological studies in this area. The present study is done with IgM ELISA as a diagnostic test which has higher sensitivity and specificity as most of previous studies had used Weil Felix test as a diagnostic test. METHODOLOGY: This was a prospective observational study. All the patients more than 18 years of age with positive IgM ELISA for scrub typhus with or without eschar were included. The clinical profile was observed. IgM scrub typhus was done by kit method manufactured by InBios International, Inc. RESULTS: Total 330 patients were observed. Maximum patients were observed in August, September, and October. Fever was the most common presenting complaint. Eschar was present in 40.61% patients. Complications were seen in 71.2 %. CONCLUSIONS: The general physicians should be sensitized for the early diagnosis to reduce mortality.