Shorter antitubercular therapy for extrapulmonary tuberculosis - a case report.

INTRODUCTION: Extrapulmonary tuberculosis (EPTB) adds to India's significant economic burden, with pericardial effusion being a potentially fatal complication. This case report highlights the need for early diagnosis and the feasibility of shorter-duration treatment for EPTB in developing countries. PRESENTATION: This case report describes a 19-year-old male from Southeast Asia who had a history of bronchiectasis involving the left lower lobe and the right middle lobe, which was cystic in nature, as well as multiple episodes of non-tuberculous pneumonia. Currently, he presented with fever, hypotension, tachycardia, and acute kidney injury. Echocardiogram showed left ventricular dysfunction with a left ventricular ejection fraction (LVEF) of 45% and moderate pericardial effusion. Early signs of cardiac tamponade were noted, specifically the absence of respiratory variation in the right ventricle and left ventricle collapse. Emergent pericardiocentesis was performed, and hemorrhagic pericardial fluid was aspirated. Fluid analysis revealed high levels of LDH (5000 U/L), polymorphonuclear leukocytosis, and acid-fast bacilli that were visualized on microscopy, which led to the diagnosis of pericardial tuberculosis. A CT of the abdomen showed hepatosplenomegaly and polyserositis. Empirically, antitubercular therapy consisting of isoniazid, rifampin, pyrazinamide, and ethambutol was administered for 2 months and isoniazid along with rifampicin was given for the next 4 months. Serial echocardiograms in the following months showed an improvement in LVEF (55%) and decreased effusion. However, during this treatment period, due to frequent episodes of pneumonia, the evaluation of immunodeficiency disorders was performed and revealed low levels of IgG (4.741 g/L), IgA (0.238 g/L), and IgM (0.098 g/L). He was diagnosed with common variable immunodeficiency disease and received intravenous immunoglobulin therapy. CONCLUSION: This report emphasizes the timely identification of cardiac tamponade and the effective management of EPTB through a shorter-than-recommended course of antitubercular therapy, resulting in the alleviation of symptoms and better overall health outcomes.

Paradoxical septic embolism in an Ebstein's anomaly patient leading to brain abscess: A case report.

Ebstein's anomaly (EA), a congenital cardiac anomaly, is characterized by apical displacement of the tricuspid valve leaflet(s) into the right ventricle. We present the case of a 61-year-old female with a history of EA, Wolff-Parkinson-White syndrome, and patent foramen ovale (PFO), who presented with worsening hypoxia and confusion, in the setting of left lower extremity cellulitis and abscess. The computed tomography (CT) scan of the head showed a cerebellar infarct with hemorrhagic conversion. Magnetic resonance imaging of the head showed a satellite lesion raising concern for the embolic nature of infarcts. After ruling out cardioembolic causes of cerebellar infarction, her presenting symptoms were attributed to paradoxical septic emboli from the left leg abscess (demonstrated on CT scan of the leg). She was deemed a poor candidate for surgical closure of PFO due to contraindication to use heparin (due to the presence of hemorrhagic stroke) and underlying comorbidities. Septic embolization is a rare but dreaded complication in EA patients with PFO. Learning objective: •Paradoxical emboli can occur in patients with Ebstein's anomaly (EA) and patent foramen ovale (PFO).•The mainstay of management in case of paradoxical embolism lies with the identification and treatment of the underlying cause, such as infective endocarditis, deep vein thrombosis, or infectious source, as in the present case.•The surgical correction of PFO in EA patients should be considered when the patient becomes symptomatic with cyanosis, hypoxia, or manifestations of paradoxical emboli.

Hypoattenuated Leaflet Thickening-Associated Myocardial Infarction: A Rare Case Report and Literature Review.

Hypoattenuated leaflet thickening (HALT), a potential aftereffect of transcatheter aortic valve replacement (TAVR) procedure, may affect valve performance and clinical outcomes. At this moment we describe an elderly patient who, despite being on prophylactic antiplatelet medication for previous percutaneous intervention (PCI) for coronary artery disease (CAD) and a self-expanding valve in-situ for aortic stenosis (TAVR), presented to the emergency room with non-ST-segment elevation myocardial infarction (NSTEMI), probably as a result of a thromboembolic event from HALT. The case highlights the significance of considering HALT-associated thromboembolism as a potential cause of myocardial infarction (MI) in post-TAVR patients.

Early-onset familial hypercholesterolemia: A case of extensive xanthomas and premature coronary artery disease.

Key Clinical Message: Early recognition and management of familial hypercholesterolemia (FH) are crucial, especially in patients with extensive xanthomas and premature coronary artery disease. Prompt diagnosis and aggressive lipid-lowering therapy can significantly reduce morbidity and mortality rates. Careful clinical assessment in resource-limited settings is essential for optimal outcomes. Abstract: Familial hypercholesterolemia (FH) is an autosomal dominant inherited disorder that causes chronically elevated levels of low-density lipoprotein (LDL) cholesterol. Based on LDL levels, FH can be heterozygous or homozygous, further established through clinical features, laboratory findings, and genetic analysis. Elevated cholesterol levels cause atherosclerosis, coronary artery disease, myocardial infarction, and sudden death. Xanthomas are a clinical manifestation of FH that reveal the underlying systemic genetic disease. We present the case of a 47-year-old male with triple vessel coronary artery disease and widespread xanthomas, diagnosed with homozygous FH based on "The Dutch Lipid Clinic Network Diagnostic Criteria for Familial Hypercholesterolemia." Lifelong therapy with lipid-lowering medications and lifestyle changes is necessary in such cases.

Unveiling the Silent Intruder: H. pylori's Hidden Link to Ischemic Heart Disease.

Cardiovascular disease is the leading cause of death. In addition to the well-known risk factors associated with cardiovascular disease, such as age, diabetes mellitus, smoking, hypertension, and obesity, there has been a growing concern regarding cardiac complications stemming from the Gram-negative bacteria Helicobacter pylori. While H. pylori is most commonly associated with chronic gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric lymphoma, it has also been implicated in extra gastric manifestations, encompassing cardiac, neurologic, ocular, and dermatologic issues. Key virulent factors for coronary artery disease include the vacuolating cytotoxin gene A and the cytotoxin-associated gene A. The most likely pathogenic mechanism of the relationship between H. pylori and coronary artery disease is initiating a chronic inflammatory process associated with infection and the modifications of classic risk factors. These alterations lead to the creation of prothrombotic and procoagulant environments. Here, we review the cardiac manifestations of H. pylori and the underlying pathophysiological mechanisms.

Pembrolizumab-Induced Lichen Planus: A Rare Immune-Related Adverse Side Effect.

Pembrolizumab is the first anti-programmed death protein-1 agent approved by the US Food and Drug Administration. It has demonstrated efficacy in melanoma, lung cancer, and other advanced solid tumours and hematologic malignancies. Various dermatological side effects including pruritus, maculopapular rash, vitiligo, lichenoid skin reactions, psoriasis, and rarely life-threatening conditions like bullous pemphigoid, Stevens-Johnson syndrome, and drug rash with eosinophilia and systemic symptoms have been reported. We report a case of pembrolizumab-induced lichen planus in a 54-year-old female who was receiving pembrolizumab for management of lung metastasis from squamous cell carcinoma of the buccal mucosa. The lichen planus responded to acitretin and pembrolizumab was continued safely.

Isolated Proximal Black Esophagus in a COVID-19 Patient.

Black esophagus or acute esophageal necrosis (AEN) is a rare cause of upper gastrointestinal (UGI) bleeding usually involving distal esophagus. Proximal esophageal involvement is quite rare. We present an 86-year-old female with active coronavirus disease 2019 (COVID-19) infection who came in with newly diagnosed atrial fibrillation and was started on anticoagulation. She subsequently developed a UGI bleed, which was complicated by inpatient cardiac arrest. Following resuscitation and stabilization, UGI endoscopy showed circumferential black discoloration of proximal esophagus, with distal esophageal sparing. Conservative management was instituted and fortunately, repeat UGI endoscopy two weeks later showed improvement. This describes the first case of isolated proximal AEN in a COVID-19 patient.

Digital impact of world hepatitis day: Formulating evidence-based recommendations for promoting healthcare awareness events.

BACKGROUND: Social media applications provide room for public interaction and forming communities, thus helping disseminate health-related information. Since 2010, World Hepatitis Day has been observed on July 28 with endorsement from the World Health Organization. This study aimed to ascertain the global digital impact of World Hepatitis Day on Twitter (an online microblogging social network) and on the web (web searches and news) to formulate evidence-based recommendations for promoting future policy development. MATERIALS AND METHODS: We analyzed publicly available data from Twitter, a popular microblogging social network on the internet (data accessed from India). Three social media assessment tools (Sprout social, SocioViz and Symplur) and Google Trends were used to obtain data about the tweets and global impressions worldwide about World Hepatitis Day. A time frame from July 27th, 2022 to July 29th, 2022 was taken into account for all the tweets in various time zones around the world. RESULTS: "#WorldHepatitisDay" and "#Hepatitis" received 519.16 million and 412.37 million impressions in the defined timeframe, respectively. A total of 39,069 tweets were posted about World Hepatitis Day, an increase of 24.1% compared to the previous year. On social network analysis, 93 of the top 100 influencers collaborated among themselves, which helped in the wider dissemination of awareness. CONCLUSIONS: World Hepatitis Day 2022 was an impactful healthcare awareness event on Twitter for the global audience and sets forth an example of the effective utilization of resources. Future policies shall inculcate constructive feedback from our findings and must be inclusive of all the underrepresented communities.

A nationwide survey on the preference of Indian undergraduate medical students to go abroad for higher studies and residency.

Context: Getting residency training abroad is a critical motivator in the emigration of Indian medical students. Brain drain is an emerging issue, especially for developing countries as it causes a shortage of trained staff in the donor country. Aim: We aimed to survey Indian medical students to know about their intentions to get trained abroad and to understand the factors influencing their decision. Materials and Methods: In this cross-sectional observational study, we surveyed Indian undergraduate medical students of all professional years, including internship. A validated questionnaire collected data on students' demographics and educational characteristics, intention to study overseas or stay back in India, and factors influencing their decision. Results: Out of a total of 1199 responses (51.1% males, 48.9% females), 45.0% partakers had planned to pursue their residency abroad, while 33.8% wanted to stay in India and 21.2% were undecided. Better lifestyle and higher pay grades overseas were viewed as the most significant barriers to staying back in India and a key influencer in decision-making among the maximum number of students (412; 76.3%). On the other hand, a whopping 58.2% of participants opined that they wanted to stay back in India for taking care of their parents. Conclusions: Source countries with better healthcare facilities and better incomes tend to attract medical students. Awareness among medical educators regarding constantly changing curricula, a shift to a competency-based education system, better pay grades, limited working hours, and interventions to mitigate workplace violence could help prevent brain drain among Indian medical students and graduates.

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index.

INTRODUCTION: The prevalence of lower extremity artery disease (LEAD) continues to increase worldwide. This is expected to translate into logarithmic rise in lower-limb amputations especially in the developing world. Majority of patients suffering from LEAD remain asymptomatic until late and are vulnerable to limb-threatening complications unless actively screened and treated. METHODS: This was a prospective, single-center, observational study to determine the prevalence and predictors of LEAD. Patients with known atherosclerotic vascular disease (but not known LEAD) or those at risk were enrolled. All underwent ankle brachial index (ABI) measurement as per the standard protocol. A threshold of ABI ≤0.90 was taken to diagnose LEAD. RESULTS: A total of 1000 patients were enrolled. The mean age of the group was 61.4 ± 10.0 years and the prevalence of LEAD was 10.2%. Amongst those who had LEAD, the majority of patients (69.6%) had no symptoms. The prevalence of LEAD in diabetic population in our study was 13.2% and it was 30.9% in coronary artery disease patients . Factors independently linked to LEAD on regression analysis included advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. CONCLUSIONS: The vast majority of patients suffering from LEAD are asymptomatic. Early diagnoses and institution of appropriate medical and physical therapy can prevent excess morbidity and mortality due to LEAD. Factors independently linked to LEAD are advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. The presence of either of these should signal undertaking of appropriate steps to unmask underlying LEAD.

Pyoderma Gangrenosum with Splenic Abscess- A Rare Association.

Pyoderma gangrenosum is a rare, chronic neutrophilic dermatosis of unknown etiology. The classical clinical feature of pyoderma gangrenosum is a pustule or plaque that rapidly progresses to a painful, necrotic ulcer with undermined violaceous margins. Pyoderma gangrenosum may be associated with underlying inflammatory bowel diseases, hematological malignancies, or rheumatologic disorders in 50-70% of the cases. The visceral involvement by pyoderma gangrenosum is rare. Sterile neutrophilic infiltrates in organs other than the skin are uncommon systemic manifestations of neutrophilic dermatoses, but have occasionally been reported. We report a case of a 38-year-old female with pyoderma gangrenosum and visceral involvement manifesting as splenic abscess.

Assessment of diabetes risk profile in a rural population of northern India using the Indian Diabetes Risk Score - A community-based study.

Background: Diabetes is one of the leading killers among noncommunicable diseases of the present time and poses a considerable burden to the society in terms of public health. The Indian Diabetes Risk Score (IDRS) can be used as a risk assessment tool to estimate the population at risk and plan appropriate interventions. The present study was conducted to assess the diabetes risk profile of a rural population of Punjab by using IDRS. Materials and Methods: This was a cross-sectional study conducted in two phases after obtaining approval from the Institutional Ethics Committee. Phase 1 was done in Rural Health Training Center (RHTC), Pohir, where every fifth patient attending the outpatient department was included in the study. Phase 2 was conducted in village Gopalpur, which is one of the villages in the field practice area of Department of Community Medicine, where participants were enrolled by conducting house to house survey after taking their informed consent. Sociodemographic characteristics, risk factor profile, and the IDRS of the participants were noted. The data was analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0 to calculate the percentages. Pearson's Chi-square test was used for qualitative variables, and mean, standard deviation and analysis of variance (ANOVA) were used for quantitative variables. A P value of less than 0.05 was considered significant. Results: A total of 252 subjects (99 male and 153 female) from RHTC and 213 subjects (71 male and 142 female) from village Gopalpur participated in the study, with their mean IDRS being 44.8 ± 15.7 and 46.6 ± 21.1, respectively. On calculating the IDRS of participants enrolled in RHTC, it was found that 15.5% had low, 56% had moderate, and 28.5% had high risk, whereas from village Gopalpur, 19.2% had low, 57.3% had moderate, and 23.5% had high risk for developing diabetes mellitus. The risk for developing diabetes was found to be higher among females, subjects living in joint families, and subjects with high body mass index (BMI). The mean systolic and diastolic blood pressure showed an increasing trend with increase in IDRS score of the participants. Conclusion: The present study showed that even in rural areas, nearly one-fourth of the adult population was at high risk, whereas more than half of the population was at moderate risk of developing diabetes mellitus. This corroborates the World Health Organization's (WHO's) stand to declare diabetes as a public health emergency and to devise ways to urgently mitigate this problem. Therefore, awareness and health education campaigns should be implemented in rural areas for early identification of risks, which will help in prevention and hence decreasing the burden of the disease.