Anand Date

Nondiabetic renal disease in noninsulin-dependent diabetics in a South Indian hospital

Eighty patients with non-insulin-dependent diabetes mellitus being treated in a south Indian hospital were biopsied to confirm suspected nondiabetic renal disease (NDRD). The positive predictive value of the standard clinical indicators for NDRD in the presence or absence of diabetic retinopathy was 54 and 87%, respectively. These values are higher than those given by comparable studies in Western populations. This is probably due to a higher prevalence of NDRD in the population of south India, and especially of proliferative glomerulonephritis, which was found in 21.5% of the patients studied. Standard clinical predictors of NDRD in diabetics have a high predictive value in the tropics where there is a high prevalence of proliferative glomerulonephritis.

Light and electron microscopic findings in rhinosporidiosis after dapsone therapy

Morphological findings in serial nasal mucosal biopsies from three cases of rhinosporidiosis on dapsone therapy were compared with biopsies from 33 patients taken before dapsone or surgical treatment was initiated. All biopsies were examined by light microscopy and five by electron microscopy. Counts of histologically intact and degenerated organisms showed a decreasing proportion of intact forms with treatment.

Terminal Infections in Renal Transplant Patients in a Tropical Environment

Infections were a major cause of death in 84% of 38 autopsied renal allograft recipients in a south Indian hospital. Pyogenic bacteria and fungi were the most common etiological agents encountered, being present in 50 and 47% of cases, respectively. Tuberculosis and hepatitis B virus infection were more prevalent and Pneumocystis carinii and cytomegalovirus disease rarer than in comparable series from non-tropical countries. 1 case each of amoebiasis, strongyloidiasis and filariasis were the parasitic infections encountered.

Minimal-Change Nephrotic Syndrome in Adults Treated with Alternate-Day Steroids

Fifty-eight previously untreated adults with minimal-change nephrotic syndrome (MCNS), who had a mean follow-up period of 35.8 months, were studied with regard to their response to alternate-day steroid therapy. The nephrotic syndrome in 54 patients (93%) remitted by 12 weeks and patients continued to be in remission at 16 weeks. Of the 54 patients, 8 (14.8%) had frequent relapses and 9 (16.6%) had infrequent relapses. No serious complications as a result of steroid therapy were encountered.

Histological studies in primary neuritic leprosy : changes in the nasal mucosa

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Leprosy and renal transplantation

Nine cases of leprosy in patients treated at a large renal transplant centre in South Asia are described. Three had leprosy diagnosed before transplantation and had either completed or were continuing chemotherapy at the time of transplantation. One showed exacerbation of undisclosed leprosy after transplantation. Five patients developed the disease for the first time 22 months to 12 years after transplantation. Immunosuppression did not adversely affect the treatment of leprosy in any of the patients though concurrent liver disease required cessation of rifampicin in one patient.

Atypical copper cirrhosis in Indian children.

In addition to ten children with Wilsons disease and one with Indian childhood cirrhosis, nine Indian children, aged from 4 to 15 years, with cryptogenic cirrhosis had significant deposits of stainable copper in their hepatocytes. These nine children had normal or elevated serum caeruloplasmin levels, absence of Kayser-Fleischer rings and a history of sibling death owing to liver disease in four cases. Histologically, fatty change was absent from all the biopsies but Mallorys hyaline, pericellular fibrosis and ballooning of hepatocytes were present in some. Since these children did not conform to the accepted clinical or histological definitions of either Indian childhood cirrhosis or Wilsons disease, they were designated as having atypical copper cirrhosis. The relationship of this group of cases to other types of copper cirrhosis is unknown.

Haemolytic-uraemic syndrome complicating snake bite.

Anand Date, MD, Professor of Pathology, Christian Medical College Hospital, Vellore 632004, Tamil Nadu (India) Dear Sir, The triad of acute renal failure (ARF), thrombocyto-penia and haemolytic anaemia with fragmented erythrocytes (schistocytes) comprise the haemolytic-uraemic syndrome (HUS) [1]. In addition to its primary idiopathic childhood form, this syndrome can occur secondarily with viral and bacterial infections, oral contraceptive use and in pregnancy and in the puerperium [2]. Its occurrence after snake bite is not well known. During the period 1975–1983, 12 female and 12 male patients, with a mean age of 36 years (SD 14 years), were treated for ARF following snake bite at the Christian Medical College Hospital at Vellore in southern India. They had been referred for treatment from peripheral clinics 2–21 days after the onset of oliguria. Initially the patients had severe pain and swelling at the site of the bite and bleeding manifestations, most commonly haematu-ria with prolonged bleeding and clotting times. Oliguria or anuria developed within 24 h of the bite, and lasted for 4–47 days. The snake was identified by description as Vipera russelli in 7 cases. In the remainder, identification could not be made, although the symptomatology suggested that the Russell’s viper was involved in all cases and this is the only snake in this region whose bite is reported to cause ARF [3]. Results of laboratory investigations were as follows: Blood urea, mean 46.5, SD 25 mmol/l; plasma creati-nine, mean 967, SD 417 μmol/l; platelet count, mean 104, SD 92 × 10V1; packed cell volume, mean 0.27, SD 0.11; reticulocyte count, mean 5, SD 3%; total leukocyte count, mean 13.3, SD 4× 10V1; differential neutrophil count, mean 80, SD 8%. Schistocytes were present in the peripheral blood smears of 22 patients. Sixteen patients had HUS with anaemia, schistocytosis and thrombocyto-penia. Six patients had normal platelet counts when first examined 7 days or more after the bite, and there was no record of schistocytes in the peripheral blood smear in 2 cases. Absence of the complete triad could, in most cases, be attributed to incomplete or delayed investigation. Percutaneous renal biopsies performed in 15 patients showed cortical necrosis in 3 cases and acute tubular necrosis in the rest. Fibrin and platelet clusters were demonstrable in glomeruli and small calibre blood vessels in 5 of the 7 biopsies examined electron microscopically [4, 5]. Two patients were treated conservatively, 2 with hae-modialysis and the rest by peritoneal dialysis. One patient died of massive haematemesis soon after admission to hospital. Patients with cortical necrosis developed chronic renal failure, the others made a complete recovery.

The pattern of liver disease in Indian children: a review of 128 biopsied cases.

We report the pattern of childhood liver disease revealed by a study of 134 biopsies obtained from 128 infants and children below the age of 16 years seen in this hospital during a 3-year period. The most common histological diagnoses were neonatal hepatitis syndrome in 23, storage disorders in 11, and cirrhosis in 26 children. Less common diagnoses included Reyes syndrome in four, fatty liver in seven, granulomas in four, and chronic active hepatitis, fulminant hepatitis, congenital hepatic fibrosis and neoplasms in two children each. Miscellaneous specific diagnoses were made in 16 cases. Twenty-three per cent of the liver biopsies were non-diagnostic. The study has provided background information on the occurrence of specific histological diagnoses in liver biopsies in infants and children in this tropical region and identifies a group with cirrhosis and copper deposition which was not typical of either Indian childhood cirrhosis or Wilsons disease.

Central nervous system disease in renal transplant recipients.

Anand Date, MD, Professor of Pathology, CMC Hospital, Tamil Nadu (India) Dear Sir, Diseases of the central nervous system (CNS) are an important cause of morbidity and mortality in renal transplant recipients [1]. Since there are few reports reviewing these lesions, we describe here the CNS complications that occurred in 38 of the 550 patients who received live-donor renal allografts at our centre during a 15-year period. The findings and methods of diagnosis are summarised in table I. As expected from other reports [1–3], infections were the commonest CNS complications, being seen in cases 1–16. However, tuberculous meningitis was much more frequent reflecting the higher prevalence of tuberculosis in the tropics. Case 4 who died of gram-negative bacillary septicaemia had microglial nodules in the pons; such lesions have been reported previously and are believed to be due to cytomegalovirus or herpes simplex virus infection [3, 4]. Cryptococcus was the fungus most frequently involving the CNS, though it is uncommon among all systemicfungal infections in suchpatients here [5]. Cerebrovascular accidents occurred in cases 17–25 including 8 of the 283 renal transplant recipients treated using a high-dose steroid schedule employed earlier and in only 1 of the 267 cases who were given steroids according to the newer low-dose regimen. This difference was statistically significant by Fisher’s exact test (p < 0.02). All these patients had hypertension and 2 had diabetes mellitus as well. Eight patients presented with convulsive disorders, of whom 4 had hypertensive encephalopathy and 2 idio-pathic epilepsy. Patients 30 and 31 had generalised convulsions with serum calcium levels of 0.95 and 1.05 mmol/l, respectively. Detailed investigations failed to reveal any cause for hypocalcaemia, but both patients improved with calcium supplements. All 3 patients with hepatic encephalopathy had HBs antigenaemia. Case 37 developed drowsiness 5 months after transplantation, at which time renal functions were only mildly impaired and other investigations including cerebrospinal fluid examination were normal. A CAT scan and EEG showed evidence of bilateral frontal lobe atrophy of unknown cause. Extensive investigations including a diagnostic laparotomy failed to show the cause of fever in case 38, but necropsy revealed pulmonary nocardiosis and central pontine myelinolysis