Cutaneous Manifestations in Patients with Beta-Thalassemia Major.

BACKGROUND: Beta-thalassemia major is a transfusion-dependent thalassemia. Both ongoing disease-related inflammatory processes and chronic transfusions lead to iron overload, which is depicted by hyperferritinemia. We aimed to report the prevalence of various dermatological manifestations in beta-thalassemia major patients and their relationship with serum ferritin levels. MATERIAL AND METHODS: This was a cross-sectional study conducted over a period of six months. Beta-thalassemia major patients were consecutively enrolled and examined by a dermatologist who charted any skin conditions, if present. A blood sample was also taken at the same time to check for the serum ferritin levels. Data was analysed using SPSSv25. RESULTS: A total of 113 patients were included in the study. The mean age of the cohort was 9.32 ± 4.54 years. The mean ferritin level for the cohort was 3334 ± 1676 micrograms per litre. Cutaneous manifestations were seen in 89.4% (n = 101) patients with the common ones namely xerosis (44.2%), freckles (39.8%) and pruritus (44.2%). We noted that serum ferritin levels were significantly higher in those with freckles (p = 0.00288). The cause of pruritus does not appear to be jaundice (p = 0.973). Lastly, number of skin conditions were higher in those with onset of blood transfusions at age less than one year (p = 0.0011). CONCLUSION: Dermatological manifestations are a frequently encountered problem in beta-thalassemia major patients. It is important to examine these patients for various skin disorders periodically as this can help improve their quality of life and reduce dermatological-associated morbidity.

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography in Comparison With Endoscopic Retrograde Cholangiopancreatography for Detection of the Etiology of Obstructive Jaundice.

BACKGROUND: Despite technological advances, obstructive jaundice has significant morbidity and mortality rates. When studying obstructive jaundice, endoscopic retrograde cholangiopancreatography (ERCP), the "gold standard" for biliary obstruction identification, might be replaced with magnetic resonance cholangiopancreatography (MRCP), which is a non-invasive procedure. OBJECTIVE: Diagnostic accuracy of MRCP in comparison with ERCP for the detection of the etiology of obstructive jaundice. METHODOLOGY: This prospective, observational study included 102 patients who presented with obstructive jaundice as proven by liver function tests. The MRCP was conducted within 24 to 72 hours before the ERCP. A torso phased-array coil (Siemens, Germany) was used for the MRCP. The duodeno-videoscope and general electric fluoroscopy were used to perform the ERCP. The MRCP was evaluated by a classified radiologist who was blinded to the clinical details. An experienced consultant gastroenterologist who was blinded to the results of the MRCP assessed the cholangiogram of each patient. The hepato-pancreaticobiliary system results from both procedures were compared based on the pathology observed, such as choledocholithiasis, pancreaticobiliary strictures, and dilatation of biliary strictures. We determined the sensitivity, specificity, and negative and positive predictive values with 95% confidence intervals. The statistical significance was set at p<0.05. RESULTS: The most commonly reported pathology was choledocholithiasis, and MRCP diagnosed 55 patients, of which 53 were true positive cases when compared with the ERCP results of the same patients. MRCP demonstrated greater sensitivity and specificity (respectively) for screening choledocholithiasis (96.2, 91.8), cholelithiasis (100, 75.8), pancreatic duct stricture (100, 100), and hepatic duct mass (100, 100) and showed statistically significant values. The sensitivity of MRCP is lower for identifying benign and malignant strictures, but its specificity was observed to be reliable. CONCLUSION: When it comes to determining the severity of obstructive jaundice, both in its early and later stages, the MRCP technique is widely regarded as a reliable means of diagnostic imaging. The diagnostic function of ERCP has been significantly reduced as a result of the precision of MRCP as well as its non-invasive nature. In addition to being a helpful non-invasive method to identify biliary diseases and avoid unnecessary ERCPs and their risks, MRCP offers good diagnostic accuracy for obstructive jaundice.

Acute Cholecystitis Masking a Gastric Bezoar.

A bezoar is a solid mass of indigestible material that usually forms in the gastrointestinal (GI) tract. Gastric bezoars, located in the stomach, can present variably. They can be asymptomatic or present with GI symptoms like nausea, vomiting, abdominal pain, or more serious complications, such as GI obstruction or perforation. Diagnostic modalities are mainly radiological, and treatment may either be conservative or interventional. Herein, we disclose the case of a 47-year-old female who presented with a two-week history of abdominal pain with an incidental finding of a possible gastric phytobezoar, co-existing with gallbladder disease. Although not previously reported, this study highlights the possibility of an association between gallbladder disease and the formation of a bezoar.

The Macklin Effect in COVID-19.

From the mere outlook of the ongoing pandemic, coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) seems to target mainly the respiratory system, but more evolving evidence has advocated its multi-organ involvement. While various complications have been reported in coronavirus disease 2019 (COVID-19) patients, spontaneous pneumomediastinum (SP) remains an uncommon complication.

Unilateral Vocal Cord Paralysis in a Patient With Acute Viral Hepatitis.

Hepatitis A virus is a leading cause of acute infectious hepatitis worldwide. The infection is characterized by a self-limiting course, and rarely has there been any occurrence of chronic sequelae or extra-hepatic manifestations. We report a case of unilateral vocal cord paralysis in a patient with acute hepatitis A.

Essential Palatal Tremor Following an Upper Respiratory Tract Infection: A Case Report.

Bilateral objective tinnitus is a rare accompanying manifestation of an underlying palatal tremor (PT). PT can either be secondary to a lesion in the triangle of Guillain and Mollaret, or it can present without a causal organic lesion. In this report, we present an unusual case of a young female with objective tinnitus revealing a PT.

Multisystem Inflammatory Syndrome in Children and Adolescents (MIS-C) under the Setting of COVID-19: A Review of Clinical Presentation, Workup and Management.

Earlier in its course, SARS-CoV-2 was primarily identified to cause an acute respiratory illness in adults, the elderly and immunocompromised, while children were known to be afflicted with milder symptoms. However, since mid-April of 2020, latent effects of the virus have begun emerging in children and adolescents, which is characterised by a multisystem hyperinflammatory state; thus, the term Multisystem Inflammatory Syndrome in Children (MIS-C) was introduced by the WHO and CDC. The syndrome manifests itself approximately 4 weeks after COVID-19 infection, with symptoms mimicking Kawasaki Disease and Kawasaki Disease Shock Syndrome. Demographically, MIS-C peaks in children aged 5 to 14 years, with clusters in Europe, North and Latin America seen, later followed by Asia. Although the exact pathophysiology behind the syndrome is unknown, recent studies have proposed a post-infectious immune aetiology, which explains the increased levels of immunoglobulins seen in affected patients. Patient presentation includes, but is not limited to, persistent fever, rash, gastrointestinal symptoms and cardiac complications including myocarditis. These patients also have raised inflammatory markers including C reactive protein, ferritin and interleukin-6. In poorly controlled patients, the syndrome can lead to multiorgan failure and death. The mainstay of treatment includes the use of intravenous immunoglobulins, steroids, immune modulators and aspirin. Adjunct therapy includes the use of low molecular weight heparin or warfarin for long term anticoagulation. Currently very little is known about the syndrome, highlighting the need for awareness amongst healthcare workers and parents. Moreover, with increased cases of COVID-19 as a result of the second wave, it is essential to keep MIS-C in mind when attending patients with a past history of COVID-19 exposure or infection. Additionally, once these patients have been identified and treated, strict follow-up must be done in order carry out long term studies, and to identify possible sequelae and complications.

Short-Term Effect of Inhaled Salbutamol on Heart Rate in Healthy Volunteers.

Objective Tachycardia is a potential side effect of salbutamol inhalation. We aimed to study the short-term effect of salbutamol nebulization on the heart rate of healthy volunteers. Material and methods A randomized, single-blinded, placebo-controlled, cross-over study was conducted with 30 healthy volunteers divided into two groups of 15 each. One group was nebulized with salbutamol (2.5 mg/2 ml dilution) while the other group was given normal saline (2 ml). Each arm underwent administration of the opposite drug the following week. Baseline readings of heart rate and blood pressure were taken at zero (T0), seven (T7), 15 (T15), and 30 (T30) minutes. Results Thirty volunteers between the ages of 20 and 25 years were studied. The mean heart rate value was higher for nebulized salbutamol at each point as compared to saline. When nebulized with salbutamol, the heart rate had a significant rise (p= < 0.00001) at 15 minutes as compared to saline nebulization. Conclusion Salbutamol nebulization, even at a low dose, can lead to a significant increase in heart rate when compared to nebulization with normal saline in healthy individuals.

Follow-up of COVID-19 recovered patients with mild disease.

COVID-19 may manifest as mild, moderate or severe disease with each grade of severity having its own features and post-viral implications. With the rising burden of the pandemic, it is vital to identify not only active disease but any post-recovery complications as well. This study was conducted with the aim of identifying the presence of post-viral symptomatology in patients recovered from mild COVID-19 disease. Presence or absence of 11 post-viral symptoms was recorded and we found that 8 of the 11 studied symptoms were notably more prevalent amongst the female sample population. Our results validate the presence of prolonged symptoms months after recovery from mild COVID-19 disease, particularly in association with the female gender. Hence, proving the post-COVID syndrome is a recognizable diagnosis in the bigger context of the post-viral fatigue syndrome.

Postpartum-Acquired Hemophilia A Presenting as Hemoperitoneum: A Case Report.

Acquired hemophilia A (AHA) is a bleeding diathesis caused by the production of autoantibodies to factor VIII (FVIII). It manifests as an isolated deranged activated partial thromboplastin time (aPTT) indicating a defect in the intrinsic coagulation pathway. Herein, we report a case of a 26-year-old woman who presented with hemoperitoneum in the postpartum period following a lower segment Caesarean section (LSCS). AHA carries significant mortality if it remains undiagnosed, and early recognition and measures to eradicate the acquired inhibitors are the mainstays of its management.

Idiopathic Dilatation of Inferior Vena Cava: A Case Report.

Inferior vena cava (IVC) is a large collapsible vein whose diameter and extent of inspiratory collapse are known to correlate with right atrial (RA) pressures; hence, IVC dilatation represents a cardiac pathology. IVC dilatation in the absence of any cardiac involvement is termed as idiopathic. We report a case of a 39-year-old male who presented with abdominal pain and had an incidental finding of isolated IVC dilatation with diminished inspiratory collapsibility and normal RA pressures. This case report emphasizes that IVC dilatation may not always have an underlying cardiac pathology.

Prevalence of Microalbuminuria in Type 2 Diabetes Mellitus.

OBJECTIVE: The presence of albumin in the urine is a marker of glomerular involvement in type 2 diabetes mellitus (T2DM), depicting diabetic nephropathy. Strict glycemic control can prevent and delay the occurrence of microalbuminuria and other diabetic complications. Therefore, we conducted a study to report the prevalence of microalbuminuria in type 2 diabetics along with its association with diabetic control. METHODS: A total of 133 patients with T2DM were consecutively included and their co-morbidities, body mass index, mode of treatment of diabetes (oral hypoglycemic drugs and/or insulin), duration since diagnosis of T2DM, and hemoglobin A1c (HbA1c) levels were recorded. A morning, mid-stream urine sample was collected and a urine spot for albumin:creatinine ratio (UACR) was assessed. Descriptive and analytic statistics were drawn with different variables and UACR values. RESULTS: The mean age of the participants was 54.5 ± 10.3 years which included 60.9% males and 39.1% females. The overall incidence of diabetic nephropathy was 30.1%, with 25.6% having microalbuminuria and 4.5% having macroalbuminuria. Pearson correlation test was used to compare UACR and duration of diabetes (p=0.034) and HbA1c (p=0.001). CONCLUSION: UACR was higher in patients with uncontrolled T2DM (in terms of higher HbA1c value) and with a longer duration since diagnosis. We recommend that UACR should be inculcated in routine practice, annually, for all patients with T2DM for gauging the development of underlying renal involvement and prompt management.

Comparison Between Menstrual Migraine and Menstrual-Unrelated Migraine in Women Attending Gynecology Clinics.

Background Migraine is amongst the top 10 most disabling conditions, and the disease burden is highest in young and middle-aged women. Another variant of the migraine headache, menstrual migraine (MM) is experienced by this cohort of patients. Former studies have done comparisons between various demographic and clinical features of MM versus menstrual-unrelated migraine (MUM) in patients presenting to various clinics with the primary complaint of headaches. We aimed to compare symptoms of migraine in women attending gynecology outpatient clinics, regardless of their presenting complaint. This would help lessen the selection bias and produce more generalizable results. Methods and materials A cross-sectional study was conducted in the outpatient gynecology clinics at a tertiary care hospital over six months. The clinic attendees were screened for sufferers of a primary headache of the migraine type. The migraineurs were then stratified into groups A, MM patients, and group B, MUM patients, using the International Headache Society (HIS) criteria. They were then questioned for the presence of various symptoms associated with their migraine attacks for comparison. Results One-hundred eighty-one women (between 12 years to 55 years) were found to have primary headaches; amongst these, 126 patients met the inclusion criteria and consented to participate; from these, 62 (49.2%) patients had MM and 64 (50.8%) patients had MUM. The symptoms of nausea (p=0.00269), photophobia (p=0.000088), and phonophobia (p=0.0281) were statistically higher in MM patients while vomiting was not a significant feature. Both groups had a predominantly unilateral headache. The average days of the attack had a significant difference between the two groups (p=0.000019), where the duration was longer for MM patients. Conclusions It was observed that patients with MM tend to experience more features associated with migraine headaches, including a longer duration of attacks, and have a worse experience overall.