Hyponatremia Among Elderly Hospitalized Patients: An Observational Study.

Aim The aim of this study is to analyze the demographic distribution (age and gender distribution), presenting symptoms, and evaluate the underlying etiology of hyponatremia among the study population. The presence of comorbidities and the volume status (hypovolemia, euvolemia, or hypervolemia) of elderly hyponatremic patients with varying severity of hyponatremia were assessed. Methods This cross-sectional, observational study was conducted in Dr. D. Y. Patil Hospital and Research Centre, Pune, India. After approval from the Institutional Ethics Sub-Committee (approval number: IESC/PGS/2022/09), it was conducted during the period between September 2022 and June 2024. The minimum sample size was calculated to be 96 with a confidence interval of 95% using WINIPEPI software (version 11.38). The lab values of serum sodium of all patients aged above 60 years admitted in wards and intensive care units (ICUs) were studied. Out of these hyponatremic patients, a sample size of 100 patients was randomly selected. Patients above 60 years and the patients who were on diuretic therapy were excluded from the study. Results The study included 100 elderly patients with a mean age of 73.25 ± 7.03 years, ranging from 64 to 86 years. Males predominated (63%), and severe hyponatremia (<125 mEq/L) was the most common, affecting 61% of patients. Generalized weakness (22%) and disorientation (17%) were the most frequently reported symptoms. Post-operative conditions (13%) and gastroenteritis (10%) were the leading causes. Most participants had no comorbidities (53%). Hypovolemia was present in 67% and euvolemia in 29% of the study subjects. Among hypovolemic patients, severe hyponatremia was present in 83.5% of patients. Conclusion This study highlights the significant burden of severe hyponatremia among elderly patients, particularly in male subjects and those with hypovolemia. Majority of the participants did not have any comorbidities. Additionally, the study emphasizes the need for heightened clinical vigilance in elderly patients presenting with generalized weakness and disorientation, as these were the most common symptoms associated with hyponatremia. The identification of post-operative conditions and gastroenteritis as leading causes further supports the need for comprehensive management strategies in elderly inpatients to prevent the occurrence and complications of hyponatremia.

Acute-Onset Quadriplegia Presenting With Hyperreflexia: A Dilemma in Diagnosis.

An autoimmune polyradiculoneuropathy, Guillain-Barré syndrome (GBS) is an acute, rapidly progressive, and fulminant one. Rapidly developing motor weakness along with absent reflexes, with or without sensory impairment, is the hallmark of GBS. GBS is never a hereditary entity; it is always acquired by the individual. Here, we present an interesting case of GBS in a 37-year-old male patient presenting with lower limb weakness for one day which had progressed to upper limb weakness in a day. There was a history of fever and loose stools four days back. On examination, vitals were within normal limits including single breath count. Central nervous system (CNS) examination revealed as follows: bicep jerk, tricep jerk, and supinator jerk were National Institute of Neurological Disorders and Stroke (NINDS) scale grade 2 in bilateral upper limbs. Knee jerk was NINDS scale grade 3 in bilateral lower limbs, which was unusual considering that GBS presents with areflexia or reduced reflexes. Ankle jerk was absent in bilateral lower limbs. Plantars were mute bilaterally. Nerve conduction study was suggestive of axonal and demyelinating motor neuropathy involving all four limbs. The patient was planned for intravenous immunoglobulin at a dose of 2 g/kg/day for five days but developed an allergic reaction to the first dose; hence, the therapy was discontinued, and the option of plasmapheresis was given to which the patient refused. This is a report of a case of GBS with hyperreflexia which is an uncommon entity in the Indian subcontinent.

An Unusual Case of Fever in Paralytic Ileus.

Still's disease is frequently a condition of exclusion for patients with an unidentified cause of fever. Accompanying symptoms typically include fever, arthralgia, and a transient skin rash. The underlying pathophysiology indicates an autoimmune origin. Diagnosis is primarily clinical, often utilizing the Yamaguchi criteria. The case in question involves a 19-year-old male presenting with high-grade fever and paralytic ileus. The patient received intravenous glucocorticoids and cyclophosphamide, resulting in a rapid clinical improvement. During the follow-up, tofacitinib was initiated based on the clinical response observed.

A Study of Lipid Profile and the Correlation of Serum Uric Acid Levels in Patients With Hypertension.

Aim We examine the lipid profile and correlation of serum uric acid (SUA) levels in cases of hypertension and normotensives. Methods The current observational study spanned between April 2022 and April 2024. Throughout the research, 200 patients were examined; 100 of these patients were classified as Stage 1 or Stage 2 hypertensive (as per the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure), while the other 100 served as controls, meaning they did not have hypertension or any other medical condition that could lead to elevated SUA levels. Results It was revealed that the proportion of hypertension was higher in males compared to females. Of the total male patients, most (41.1%) patients had grade 1 hypertension and grade 2 hypertension, while among females, 20% had grade 1 hypertension. It was seen that as age increases, systolic blood pressure (SBP) and diastolic blood pressure (DBP) also rise among the two study groups, although the correlation was not statistically significant between blood pressure level and age of study subjects. The hypertensive patients have increased SBP and DBP levels when compared to the control group, which is significant. The lipid profile shows that the hypertensive subjects had significantly higher mean low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and triglyceride levels than controls. SUA levels were observed to be elevated in the hypertensive subjects implying a positive correlation between the level of uric acid and blood pressures. Conclusion We found evidence that hyperuricemia and hypertension go hand in hand. A statistically noteworthy positive connection was found between the systolic blood pressures and lipid profiles of the patients. Hypertensive patients were found to have hyperlipidemia, whereas normotensive controls had normal lipid profiles. Moreover, it was seen that there was a positive correlation between SBP and chronological age in hypertensive cases, although this was statistically not significant.

Acute Intestinal Obstruction in a Case of Cerebrovascular Accident.

Ogilvie's syndrome represents an acute form of intestinal obstruction that occurs in the absence of a detectable mechanical blockage impeding fecal passage. Hence, it is also given the name of intestinal pseudo-obstruction. It has been deemed a disease of imbalance between the arms of the autonomic nervous system with an increase in parasympathetic outflow. Most often, it has an antecedent surgical or medical illness. There is evidence for the use of IV neostigmine in such cases to prevent imminent intestinal ischemia and perforation. In the case of a non-responder, decompression of the bowel using a colonoscope and surgery have also been tried to relieve the symptoms. In the case that follows, a middle-aged man developed progressive abdominal distension in the course of his recovery from an ischemic cerebrovascular accident. Initially, he received conservative treatment for 48 hours. Subsequently, he was given IV neostigmine, which relieved his symptoms.

A Study of the Clinical Profiles of Patients With Hepatorenal Syndrome.

Background and objective Hepatorenal syndrome (HRS) is a systemic disorder that affects both the kidneys and the liver. HRS refers to the occurrence of kidney failure in individuals with advanced liver cirrhosis, portal hypertension, and ascites, without any underlying kidney disease. The interplay of systemic and portal hemodynamics causes severe constriction of blood vessels in the kidneys, which defines HRS. The study aims to illuminate the demographic profiles, etiology, and outcomes of patients with HRS. Material and methods The study was designed as a prospective, cross-sectional, hospital-based observational study conducted at Dr. D.Y. Patil Medical College, Hospital, and Research Centre in Pimpri, Pune. The study period spans from September 2022 to June 2024. Before commencement, approval was obtained from the institutional ethics committee, and informed written consent was secured from all participating patients. The sample size consists of 100 patients diagnosed with HRS, selected from the general medicine outpatient department, wards, and ICU of Dr. D.Y. Patil Hospital and Research Centre. A comprehensive clinical history was recorded for all patients, focusing on the symptoms of cirrhosis and HRS, followed by a thorough examination for related signs and symptoms. Results Among the 100 patients included in this study on HRS, 25% (N=25) fell within the age range of 18-30 years, and 76% (N=76) were identified as male. Alcoholic cirrhosis accounted for 78% (N=78) of cases, with hepatitis B infection being the subsequent leading cause. The mortality rate was 12% (N=12) while the survival rate was 88% (N=88). Conclusion This study provides insights into the demographic profile, etiology, and outcomes of HRS. The results of this study contribute valuable insights into the complex nature of HRS, highlighting the importance of early detection and monitoring to optimize patient care.

A Clinical Study of Rickettsial Fever and Factors Affecting Its Outcome.

INTRODUCTION: Rickettsiae comprise a family of obligate intracellular short gram-negative coco-bacilli and are transmitted by insects, mites, fleas, louse, and tick vectors. Scrub typhus, north-Asian tick typhus, rickettsia pox, and boutonniere fevers are common in India and Asia. In the early phase of illness during the initial five days, all these are indistinguishable among themselves; also, they mimic any other self-limiting viral fever. Patients usually present with fever, headache, myalgia, malaise, nausea, vomiting, and anorexia. Rarely do patients present with rash, or give a history of exposure to animals or tick bite. Thus, rickettsial diseases are missed in the early phase, when they are easily treatable, due to lack of suspicion. AIMS AND OBJECTIVES: To study clinical features, investigations, outcomes, and factors affecting the outcome of rickettsial fever. MATERIALS AND METHODS: This was an observational study conducted from December 2012 to November 2014 in a tertiary care hospital. The study population consisted of patients above the age of 13 years with a history of any one or more of the following: fever, headache, jaundice, altered sensorium, renal dysfunction, tick bite, a farmer by occupation, exposure to cattle or sheep or dog, multiorgan failure; with serological evidence of rickettsial infection by Weil-Felix test (ox-19/ox-2/ox-k ≥ 1:320) or rickettsial antibody IgM ≥ 1.1) or PCR positive. A sample size of 40 was considered for the final analysis of this study. Statistical analysis was done using inferential statistical tests such as the chi-square test and odds ratio (OR). RESULT: The most common presenting symptom was fever (100%) seen in almost every patient followed by body aches (72.5%), joint pain (62.5%), and jaundice (62.5%). General examination showed icterus (37.5%), hypotension (30%), edema (22.5%), lymphadenopathy (22.5%), and pallor (15%). On the day of admission, 17 patients were found to have the Weil-Felix test positive with an OR of 0.538462 (CI = 0.151-1.917), while the Weil-Felix test done in the second week was positive in 37 patients with an OR of 5.4 (CI = 0.439-63.11). Rickettsial antibodies were positive only in three patients on the day of admission with an OR of 0.381 (CI = 0.0317-4.58), while in the second week, rickettsial antibodies were positive in 27 patients with an OR of 16.25. The rickettsial PCR test was positive in 13 patients with an OR of 1.48 (CI = 0.3857-5.722). The mortality rate was significantly high in patients presenting with breathlessness and respiratory complications like pneumonia, pulmonary edema, and acute respiratory distress syndrome. Similarly, patients presented with hypotension and required Ionotropic support had a high mortality rate. CONCLUSION:  While the clinical presentation of rickettsia infection is similar, the causative species and epidemiology can vary depending on the region. It is important to recognize both the typical symptoms and the epidemiology of a given region to correctly diagnose and treat these infections promptly, as they can be associated with significant morbidity and mortality. Through this study, we attempt to bring awareness about this disease which would help clinicians to suspect and start treatment at the earliest before complications set in.

An Unusual Presentation of Wilson's Disease.

Wilson's disease affects the metabolism of copper and is a rare hereditary disorder that is inherited autosomally recessively. The liver and brain are the main organs affected by this disorder, which causes progressive hepatolenticular degeneration. A 15-year-old male patient arrived at the outpatient department (OPD) with mild abdominal pain on the right side, and both eyes showed Kayser-Fleischer (KF) rings. An abdominal ultrasound showed that the spleen was enlarged. Copper levels in urine were found to be higher. After a liver biopsy, cirrhosis, and mild chronic active hepatitis were found. The majority of hematological indicators were normal; however, a peripheral blood smear revealed mild thrombocytopenia. Wilson's disease is uncommon, so diagnosing it requires a high degree of suspicion. In circumstances of inexplicable liver cirrhosis or isolated neurological symptoms, it could go unnoticed. The only primary complaint in the case being presented was abdominal pain. However, the age upon presentation, the existence of KF rings in both eyes, and other tests helped us get the diagnosis.

Antineutrophil Cytoplasmic Antibodies Associated Vasculitis Presenting As Neuropathy.

Antineutrophil cytoplasmic antibody-related vasculitis (AAV), is a group of diseases marked by systemic symptoms and severe small vessel inflammation. The three subtypes of AAV are eosinophilic GPA (EGPA), Microscopic Polyangiitis (MPA), and Granulomatosis with Polyangiitis (GPA). The organs that get involved in the disease process are the kidneys and the upper and lower respiratory tracts, with a spectrum of neurological manifestations. Here, we present a case report of a 68-year-old man who came with complaints of tingling and numbness over bilateral lower limbs for two months accompanied by difficulty in walking and bilateral foot drop without any respiratory complaints or involvement of sensory or autonomic system who was diagnosed with AAV (c-ANCA +) on further workup. A sural Nerve biopsy was done for confirmation which was suggestive of chronic, asymmetrical axonal neuropathy with perivascular inflammation, suggestive of vasculitic neuropathy. The patient had no other organ involvement. The patient was started on glucocorticoids and cyclophosphamide therapy for 6 cycles after which his symptoms and quality of life improved drastically.