Ankush Gupta

Life-threatening calcium channel blocker overdose and its management

A young woman presented to the emergency department with complaints of nausea, vomiting, pain in the abdomen and difficulty in breathing after ingestion of 56 tablets of amlodipine 5 mg each (total 280 mg of amlodipine). She was managed using hyperinsulinaemia/euglycaemia therapy and other measures like calcium gluconate, glucagon and vasopressors. She was discharged from hospital in a stable condition after 5 days.

Images in...: DRESS syndrome

DESCRIPTION A 16-year-old boy, a known case of epilepsy on oral phenytoin (300 mg/day) and folic acid (5 mg/day) for last 6 weeks, presented with complains of high-grade fever, jaundice and generalised erythematous eruption for 15 days duration. The eruption was maculopapular at onset, which desquamated in the next 3 days and changed to exfoliative dermatitis (figure 1). The patient was on no other medication. He had generalised tender lymphadenopathy, jaundice and tender hepatomegaly. Investigations revealed haemoglobin 12 g/dl, total leucocyte count 15 700/mm, differential leucocyte count revealed eosinophils 15%, polymorphs 52%, lymphocytes 28% and monocytes 5%. Serum bilirubin was 7.6 mg/dl (0.3–1.0 mg/dl), alanine aminotransferase and aspartate aminotransferase were more than five times the normal. Biopsy of a skin rash revealed spongiosis with intraepidermal vesiculation and patchy exocytosis with no specific pathology in the dermis. All other investigations including septicaemia profile and serology for viral hepatitis were negative. Diagnosis of drug rash with eosinophilia and systemic symptoms (DRESS) syndrome due to phenytoin was made. Phenytoin was discontinued, and patient was started on oral prednisolone at the dose of 1 mg/kg/day for 2 weeks, which tapered over a period of next 4 weeks. The patient showed rapid resolution of fever, eosinophilia and progressive improvement in skin rash and liver dysfunction over a period of 3 weeks. Our patient was diagnosed as DRESS syndrome as defined by Bocquet et al. Clinical features were typical: fever, rash followed by exfoliative dermatitis, lymphadenopathy, eosinophilia and hepatitis. Drugs that commonly cause DRESS syndrome include phenytoin, phenobarbital, carbamazepine, lamotrigine, minocycline, sulphonamides, sulphasalazine, trimethoprim, allopurinol, abacavir, nevirapine, mexiletine, isoniazid, gold salts, diltiazem, atenolol, captopril, azathioprine and dapsone. DRESS syndrome usually begins several weeks after exposure to the offending drug. The overall mortality in DRESS syndrome is about 10%. The most common differential diagnoses for DRESS syndrome are Stevens-Johnson syndrome/toxic epidermal necrolysis, hypereosinphillic syndrome and Kawasaki disease.

Isolated extra pontine myelinolysis presenting as acute onset parkinsonism.

A 50-year-old woman was brought to the emergency department with complaints of altered mental status, her serum sodium at that time was 103mmol/l. Slow correction of hyponatraemia was started but despite every effort serum sodium rise was rapid. Although the patient improved initially, after 4 days she presented with features of parkinsonism. MRI brain was done and it was suggestive of features of EPM. She responded well to levodopa plus carbidopa therapy.

Visual Exploration of Unstructured Regulatory Documents

Governmental authorities publish rules and directives that govern the operations of an industry. These documents, called regulations, are meant to safeguard the interests of consumers. With increasing number, size and complexity of such documents, companies face an uphill task to comply with them. We present a cognitive system, called Cogpliance, for exploring and understanding regulatory documents with the goal of assisting compliance officers in attaining regulatory compliance. Cogpliance automatically reads natural language regulatory documents, extracts key concepts and presents an interactive information exploration user interface for answering compliance officers queries.

Cognitive Compliance for Financial Regulations

Regulations are rules and directives published by authorities to safeguard consumer interest in an industry. Compliance with such regulations is getting increasingly hard due both to the complexity of these documents, which require experts to read, understand, and interpret them manually, and to the sheer volume of regulatory change. Many CFOs rate this as their top challenge. The authors’ Cogpliance platform uses a cognitive approach to achieve regulatory compliance. Here, they describe key compliance-related tasks and demonstrate how Cogpliance helps compliance officers to handle those tasks effectively.

Paradoxical reaction to antitubercular therapy in miliary tuberculosis

An 18-year-old boy presented with fever, weight loss and loss of appetite for 6 months duration. Investigation revealed raised erythrocyte sedimentation rate, negative sputum smear examination for acid-fast bacilli, x-ray and high-resolution CT chest showed bilateral, diffuse infiltration of lung parenchyma with miliary shadows. The patient was treated as a case of miliary tuberculosis with antitubercular therapy (ATT). On the 10th day of treatment the patient developed high-grade fever, cough and breathlessness. Chest x-ray showed an increased infiltration of lung parenchyma. The patient was diagnosed as a case of paradoxical reaction to ATT and was managed successfully with steroids.

Secondary hypokalaemic paralysis

A 28-year-old man presented with acute onset, ascending-type and bilateral symmetrical areflexic motor paralysis. There was a history of fever 3 days prior to paralysis, multiple episodes of vomiting, chloroquine use and intravenous dextrose administration. Investigations revealed metabolic alkalosis with normal serum potassium level but ECG showed characteristic changes of hypokalaemia based on which patient was managed successfully. This case highlights the importance of ECG findings of hypokalaemia in the presence of non-confirmatory laboratory values while evaluating a case of acute flaccid quadriplegia.

Superior vena cava syndrome caused by Hodgkin’s lymphoma in an adolescent girl

A 14-year-old female patient presented to us with complaints of shortness of breath, swelling over upper body and dysphagia, prominent veins were visible on upper body. CT scan of chest revealed a large mediastinal mass compressing surrounding structures. Histopathology and immunohistochemistry confirmed it to be Hodgkin’s lymphoma. The patient was given a course of chemotherapy (doxorubicin, bleomycin, vinblastine and dacarabazine) and local radiotherapy. Presently she is doing well.