Alpana Raizada

Approach to a patient with urosepsis

Urinary tract infections can occur in all age groups and produce an exceptionally broad range of clinical syndromes ranging from asymptomatic bacteriuria to acute pyelonephritis with Gram negative sepsis to septic shock. In approximately one-quarter of all patients with sepsis, the focus of infection is localized to the urogenital tract. This may lead to substantial morbidity and significant economic implications. We present a review of the current approaches to managing urospesis.

Attention and information processing in end stage renal disease and effect of hemodialysis: a bedside study

Abstract The neurobehavioral syndrome of uremia in chronic kidney disease affects the functioning of the central nervous system. Cognitive impairment is one of the most important manifestations of this dysfunction. The process of hemodialysis is known to bring about conflicting changes in the cognitive status of patients. In the present study an assessment of cognitive status of patients with end stage renal disease was done in comparison to controls before and after a session of hemodialysis using simple bedside paper-pencil tests. Thirty patients of end stage renal disease on maintenance dialysis for at least one month with MMSE score >24 were assessed one hour before and one hour after hemodialysis using Digit Symbol Substitution Test, One Letter and Three Letter Cancellations tasks. Their results were compared to age and sex matched healthy controls. The patients with end stage renal disease had significantly lower performance in cognitive tests in comparison to controls. The performance improved 1 hour after hemodialysis in comparison to pre-dialysis values. However, the values after dialysis were significantly lower than in controls, thereby indicating that though the cognitive functions improved after hemodialysis, they did not reach the control levels. There was also a significant change in the biochemical parameters after dialysis. We conclude that patients with end stage renal disease suffered from cognitive impairment which improved on hemodialysis due to removal of metabolic waste products.

Profile of hospital admissions following acute poisoning from a major teaching hospital in North India.

A retrospective analysis of 584 cases of acute poisoning admitted with a medical emergency to the Department of Medicine, GTB Hospital, Delhi, over a three-year period. The patients were analysed with respect to the age, sex, mode of poisoning, type of poison consumed and mortality. Of these, 42.63% were aged 20–30 years. Poisoning was used as a suicidal agent by 63.8% of the patients. The nature of the poison could not be ascertained in 15.92% of patients. Sedatives were involved in 13.36%. Aluminium phosphide poisoning was found in 11.82%. The overall mortality was estimated to be 13.18% with 53.2% being caused by the consumption of aluminium phosphide. There has been a change in the nature of poisons consumed and the number of cases of aluminium phosphide poisoning is declining. However, aluminium phosphide poisoning still remains a major threat as it carries a high mortality rate.

Lead-induced DNA damage and cell apoptosis in human renal proximal tubular epithelial cell: Attenuation via N-acetyl cysteine and tannic acid

This study investigates the exposure of lead‐induced reactive oxygen species (ROS) generation, DNA damage, and apoptosis and also evaluates the therapeutic intervention using antioxidants in human renal proximal tubular cells (HK‐2 cells). Following treatment of HK‐2 cells with an increasing concentration of lead nitrate (0–50 μM) for 24 h, the intracellular ROS level increased whereas the GSH level decreased significantly in a dose‐dependent manner. Comet assay results revealed that lead nitrate showed the ability to increase the levels of DNA strand breaks in HK‐2 cells. Lead exposure also induced apoptosis through caspase‐3 activation at 30 μg/mL. Pretreatment with N‐acetylcysteine (NAC) and tannic acid showed a significant ameliorating effect on lead‐induced ROS, DNA damage, and apoptosis. In conclusion, lead induces ROS, which may exacerbate the DNA damage and apoptosis via caspase‐3 activation. Additionally, supplementation of antioxidants such as NAC and tannic acid may be used as salvage therapy for lead‐induced DNA damage and apoptosis in an exposed person.

Gram-negative bacterial pyomyositis in a patient with diabetes mellitus and chronic renal failure

Pyomyositis is a suppurative infection of the skeletal muscles. The predisposing conditions include immunosuppression accompanying malignancy, diabetes mellitus, renal failure, and acquired immunodeficiency syndrome, etc. We report a 49-year-old female with diabetes mellitus and chronic renal failure undergoing maintenance hemodialysis who presented with the suppurative stage of gram-negative bacterial pyomyositis due to Escherichia coli. She fully recovered following incision and drainage and appropriate antibiotic therapy. We highlight the importance of timely diagnosis of this uncommon and potentially life-threatening entity and the role of chronic renal failure and hemodialysis in causing this condition.

Role of angiotensin converting enzyme and angiotensinogen gene polymorphisms in angiotensin converting enzyme inhibitor-mediated antiproteinuric action in type 2 diabetic nephropathy patients

AIM To investigate the role of genetic variants of angiotensin converting enzyme (ACE) and angiotensinogen (AGT) genes in the antiproteinuric efficacy of ACE inhibitor therapy in diabetic nephropathy (DN) patients. METHODS In the present study, 270 type 2 diabetes mellitus patients with nephropathy were enrolled and treated with ACE inhibitor (ramipril) and followed at 6 mo for renal function and albumin excretion by estimating serum creatinine, end stage renal disease, and albumin/creatinine ratio (ACR) in urine. Genotyping of ACE I/D and AGT M235T polymorphisms were performed by using primer specific polymerase chain reaction (PCR) and PCR-RFLP techniques, respectively. RESULTS Forty-eight percent of DN patients (responders) benefited with respect to proteinuria from ACE inhibitor therapy at 6 mo follow-up. A significant reduction in ACR was observed after 6 mo treatment with ACE inhibitor irrespective of whether DN patients were micro-albuminuric (≥ 30 and < 300 mg/g creatinine) or macro-albuminuric (≥ 300 mg/g creatinine) at the time of enrollment. However, macro-albuminuric patients (55%) showed better response to therapy. A reduction in urinary ACR was found independent of genotypes of ACE I/D and AGT M235T polymorphisms although macro-albuminuric patients having TT genotype showed statistically insignificant increased response (72%). CONCLUSION ACE inhibitor therapy reduced urinary ACR by ≥ 30% in 50% of DN patients and the response is independent of ACE I/D and AGT M235T polymorphisms.

Can malaria trigger systemic lupus erythematosus

A 17-year-old girl presented with a 7-day history of fever and oliguria. There was no history of arthralgia, rash, haematuria, altered sensorium, convulsions, oral ulcers, alopecia or photosensitivity. Her family history was unremarkable. On examination she had tachypnoea, fever, anaemia, anasarca, bilateral basal crepitations in the chest and splenomegaly. Investigations on admission confirmed the anaemia (Hb: 8.6 g/dl), a normal white count (4100/mm), thrombocytopaenia (platelets: 19,000/mm), normal clotting (INR: 1.1), raised erythrocyte sedimentation (ESR: 55mm/1st h), abnormal renal function (urea: 29.6mmol/L, creatinine: 503.8 mmol/L). Liver function test was unremarkable, serum albumin was 0.078mmol/L and 24-h urinary protein excretion was 1 g. An immunochromatographic test for Plasmodium vivax was positive. Serological tests for dengue, leptospira, HIV, Hepatitis B and C virus and theMantoux test were all negative. An abdominal ultrasound scan showed a normal liver, a large spleen of 12.5 cm in length, bilateral hyperechoic kidneys, mild ascites and moderate bilateral pleural effusions. Our patient was treated with injectable artesunate and received haemodialysis in view of her oliguria, but continued to have persistent proteinuria and deranged renal function tests. Further evaluation revealed strongly positive antinuclear (ANA) and anti-double-stranded (ds) DNA antibody tests. Complement C3 levels were decreased. Polymerase chain reaction (PCR) testing for Cytomegalovirus (CMV) and Epstein–Barr virus (EBV) was negative. A renal biopsy showed diffuse proliferative glomerulonephritis (class IV lupus nephritis) with ‘full house’ immunofluorescence (Figures 1 and 2). A diagnosis of SLE (class IV) nephritis with plasmodium vivax malaria was made. Our patient was treated with pulsed methylprednisolone and cyclophosphamide monthly for 6 months together with oral prednisolone. Her renal function, proteinuria and 24-h urinary protein excretion normalized after 3 months of starting therapy.

Dengue fever presenting as hypokalemic muscle weakness

Dengue fever has emerged as a major public health problem in India. In recent years, there has been an upsurge of neurological manifestations in dengue. Here, we report reversible acute motor weakness due to hypokalemia in two confirmed cases of dengue infection. Over a course of few hours following administration of potassium, both the patients recovered without any residual neurological deficit.

Epidemic dropsy 2013: case series

Epidemic dropsy (ED) is caused due to intoxication with Argemone mexicana. Here we report a case series of three families, all of whom were residents of Uttar Pradesh, India, who presented in August 2013 with all the classical features of ED. We aim to highlight the importance of this malady even though the sale of unbottled mustard oil is illegal in India.