Ankur Mittal

A story of metformin-butyrate synergism to control various pathological conditions as a consequence of gut microbiome modification: Genesis of a wonder drug?

Graphical abstract Figure. No Caption available. Abstract The most widely prescribed oral anti‐diabetic agent today in the world today is a member of the biguanide class of drugs called metformin. Apart from its use in diabetes, it is currently being investigated for its potential use in many diseases such as cancer, cardiovascular diseases, Alzheimers disease, obesity, comorbidities of diabetes such as retinopathy, nephropathy to name a few. Numerous in‐vitro and in‐vivo studies as well as clinical trials have been and are being conducted with a vast amount of literature being published every day. Numerous mechanisms for this drug have been proposed, but they have been unable to explain all the actions observed clinically. It is of interest that insulin has a stimulatory effect on cellular growth. Metformin sensitizes the insulin action but believed to be beneficial in cancer. Like ‐wise metformin is shown to have beneficial effects in opposite sets of pathological scenario looking from insulin sensitization point of view. This requires a comprehensive review of the disease conditions which are claimed to be affected by metformin therapy. Such a comprehensive review is presently lacking. In this review, we begin by examining the history of metformin before it became the most popular anti‐diabetic medication today followed by a review of its relevant molecular mechanisms and important clinical trials in all areas where metformin has been studied and investigated till today. We also review novel mechanistic insight in metformin action in relation to microbiome and elaborate implications of such aspect in various disease states. Finally, we highlight the quandaries and suggest potential solutions which will help the researchers and physicians to channel their research and put this drug to better use.

Renal vein leiomyoma: a rare entity with review of literature.

Tumors of vascular origin are unusual. These tumors are predominantly malignant and commonly arise from the inferior vena cava. Benign smooth muscle tumors arising from renal vein are very rare. We present a case of leiomyoma of renal vein in a post-menopausal woman that clinically resembled a retroperitoneal paraganglioma.

Perinephric Stranding and Bulky Psoas Mimicking Pyelonephritis in a Case of Non-Hodgkin Lymphoma of Kidney

A 68-year-old male patient presented with fever and right groin pain. He had leukocytosis with azotemia. Computed tomography revealed enlarged right kidney with thickening and enhancement of walls of pelvicalyceal system and perinephric fat stranding, suggestive of pyelonephritis. Multiple enlarged lymph nodes encased right renal vessels and were present in the retrocaval region. The right psoas muscle was bulky. Fine-needle aspiration cytology and biopsy from the lesions showed features of non-Hodgkin lymphoma. Immunohistochemistry confirmed the diagnosis of diffuse, large, B-cell lymphoma. We emphasize lymphoma in differential diagnosis of atypical renal imaging suggestive of pyelonephritis and perinephritis.

Delayed Migration of Embolized Coil with Large Renal Stone Formation: A Rare Presentation

Delayed bleeding following percutaneous nephrolithotomy (PCNL) usually occurs due to development of the pseudoaneurysm which can be successfully managed with coil embolization. However very few cases of such complications have been reported in the literature. Here we are reporting a case of delayed post-PCNL bleeding that occurred in a 53-year-old diabetic patient operated on for renal stone. Computed tomography scan revealed a presence of the pseudoaneurysm in the segmental branch of right renal artery, which was successfully managed with coiling. Patient remained asymptomatic for the next 9 years after which he again presented with similar complaints. X-ray KUB was done which revealed a 2.7 cms renal pelvic calculus with the migrated coil in its center and a left upper ureteric calculus. His routine haemogram, coagulogram, serum electrolytes, and liver function tests, renal function tests, vitamin D3, and PTH (parathyroid hormone) were within normal limits. He underwent left laparoscopic ureterolithotomy and right percutaneous nephrolithotomy (PCNL). Intraoperatively the migrated stainless steel embolization coil was seen engulfed all around by the multiple stones in the right renal pelvis. Postoperative period was uneventful. Later he was followed in the outpatient department and was doing well. To conclude, this is the only case report of development of a large calculus around a migrated embolization coil which was successfully managed with PCNL. PCNL offers better stone clearance in cases of stones being formed over foreign bodies like fragmented double J stents, fragmented nephrostomies, or migrated embolization coil.

Bilateral retiform variant of sertoli leydig cell tumour of ovary: An uncommon tumor with review of literature.

Sertoli-leydig cell tumors are the uncommon sex-cord stromal tumors of the ovary. We report a case of 42-year-old female with retiform variant of sertoli-leydig cell tumour. She presented with the complaint of mass in abdomen for 7 years. Ultrasound revealed bilateral ovarian mass suggestive of malignancy. Bilateral salpingo-oopherectomy with surgical staging was done. The tumor was diagnosed as stage I retiform variant of sertoli-leydig cell tumor on histopathology and immunohistochemistry.

Xanthogranulomatous pyelonephritis: An uncommon entity with review of literature

Xanthogranulomatous pyelonephritis (XGP) is an uncommon entity affecting predominantly females between the ages 45-55 years. The disease is usually associated with urinary tract infection and the patient presents with flank pain, dysuria and fever. It has to be differentiated from various benign and malignant conditions including tuberculosis (TB) and renal cell carcinoma. Surgery is the definitive treatment of choice. Hereby, a case of 45-year-old, hypertensive female, who presented with uncommon condition is being reported.

Complete obliteration of post percutaneous nephrolithotomy (PCNL) pseudoaneurysm following administration of tranexamic acid.

A 45 year old male with no known comorbidities presented to our institute with history of bilateral flank pain since 2 years. He was a known case of bilateral renal stone disease who underwent pyelolithotomy on right side 28 years back. Extracorporeal shock wave lithotripsy (ESWL) was done for left side renal stone in our institute. Post ESWL patient had graveluria and complete clearance of the stones on left side. On evaluation NCCT KUB done showed multiple inferior calyceal stones in right kidney (Fig. 1). His hemogram and biochemistry were all within normal limits. He underwent right tubeless PCNL (percutaneous nephrolithotomy) for multiple inferior calyceal stones. It was a posterior inferior calyceal puncture and the procedure was uneventful. On postoperative day 2, patient had sudden onset of gross hematuria associated with clots and hypovolemic shock. Clot evacuation was done and continuous bladder irrigation was started. His hemoglobin dropped from 10.3 to 7.4 g % and he was given 2 Units of blood transfusion. CT angiography was done immediately and showed a pseudoaneurysm involving the posterior segmental branch of right renal artery (Fig. 2). Patient was planned for embolization but it was delayed for 24 h due to heavy rush in the angiography suite. During this waiting period patient was hemodynamically stabilized. He was given 1 gram intravenous tranexamic acid 8th hourly. When once the patient was taken up for embolization in the angiography suite (after 24 h), surprisingly no pseudoaneurysm was found on angiography (Fig. 3), so the embolization was abandoned as there was no definite pseudoaneurysm seen. Patient was conservatively managed with tranexamic acid for 72 h. Hematuria was settled and he had an uneventful recovery after that. Again before discharging the patient CT angiography done showed no evidence of pseudoaneurysm (Fig. 4). So we feel that this was an interesting case of post PCNL bleed due to pseudoaneurysm which got completely thrombosed, organized and obliterated due to tranexamic acid. Our experience in this case shows that conservative management of post PCNL bleed with tranexamic acid can be successful in at least some cases.

Penoscrotal lymphangioma circumscriptum following circumcision

We present a 15 year old boy with multiple vesicular lesions involving the scrotum and penile skin which developed following circumcision. Surgical excision of the penoscrotal skin with local flap cover was done. Histopathology was consistent with lymphangioma circumscriptum. To our knowledge this was the first case of penoscrotal lymphangioma circumscriptum which was seen after circumcision.

A clinicopathologic study of various breast lesions with cytohistological correlation

Context: Most of the females suffer from breast diseases during their life at some time or the other. Confirmation of breast diseases by clinical examination and pathological confirmation by fine needle aspiration cytology (FNAC) and histopathologic examination has been found to be an important part of diagnostic workup in breast diseases. Aims: To establish a clinicopathologic correlation in patients suffering from breast diseases. Settings and Design: We conducted a prospective study from December 2008 to August 2010. One hundred and twenty-one cases were enrolled using simple random sampling methods. Materials and Methods: Data including age, complaints, and clinical examination was collected from patients presenting for FNAC with breast complaints. Results: A total of 128 cases were studied which included 101 benign cases, 21 malignant cases, and 6 inadequate cases. The final 122 cases included 3 (2.5%) cases of acute mastitis, 2 cases (1.6%) of tubercular mastitis, 44 cases (36.1%) of fibroadenoma, 42 cases (34.4%) of benign breast disease with non-specific descriptive diagnosis, 2 cases (1.6%) of fibrocystic disease, 3 cases (2.5%) of galactocele, 1 (0.9%) case of lactational adenoma, 2 cases (1.6%) of cellular fibroadenoma, and 2 cases (1.6%) of phyllodes tumor. Apart from this, there were 21 cases (17.21%) of ductal carcinoma. Majority of benign cases were between 30 and 39 years of age (43.6%). Majority of malignant cases fell between 50 and 59 years of age (47.6%). Majority (61.5%) of lumps (>3 cm) were malignant, whereas 94.8% of lumps (<3 cm) were benign. Left breast was commonly involved (49.18%) than the right breast (44.26%). Superolateral quadrant (63.1%) was the most commonly involved quadrant. Histology was available for 35 benign cases (34.65%) and out of total malignant cases (21), histology was available for 14 cases (66.66%). No discrepancy was noted.

Bladder preserving approach for liposarcomatoid variant of transitional urothelial carcinoma

Urothelial carcinoma of the bladder with variant histologies is usually underdiagnosed and understaged. It is found in <25% of cases during transurethral resection of bladder tumours. The majority of cases carry a worse prognosis, with higher rates of recurrence and progression, and should be managed aggressively. Here, we report a rare case of liposarcomatoid variant of urothelial carcinoma managed by partial cystectomy and standard pelvic lymph node dissection.