Arvind Mishra

Effect of high-dose zinc supplementation with oral hypoglycemic agents on glycemic control and inflammation in type-2 diabetic nephropathy patients.

Objective: The study aims to evaluate the effect of zinc sulfate on markers of glycemic control, lipid profile and inflammation in type-2 diabetes with microalbuminuria patients. Materials and Methods: Type-2 diabetes with microalbuminuria patients on oral hypoglycemic agents (OHA) and angiotensin converting enzyme (ACE) inhibitors were selected and divided into 2 groups: One group (n = 27) continued with OHA alone, second group (n = 27) was on OHA and in addition 50 mg elemental zinc as zinc sulphate supplementation for 12 weeks. Fasting, post-prandial blood glucose, glycosylated hemoglobin, lipid profiles, inflammatory marker hs-CRP and urine microalbumin were measured. Results: There were no significant differences in biochemical status among groups at baseline. After receiving zinc, the mean fasting blood glucose (FBS), post-prandial blood glucose (PPBS) and glycosylated hemoglobin (HbA1c) were decreased significantly (P = 0.0001). Significant decrease was observed in TG (P = 0.002) and VLDL-cholesterol (P = 0.002), whereas there was no significant decrease in TC and LDL-cholesterol. The high-density lipoprotein (HDL) cholesterol was significantly (P = 0.0001) increased from baseline. Zinc supplementation had significant effects in decreasing serum hs-CRP from 10.51 ± 1.68 mg/L to 7.75 ± 1.56 mg/L (P = 0.0001) and microalbumin level from 146.87 ± 30.83 mg/day to 80.70 ± 33.99 mg/day (P = 0.0001). There were no significant changes in the levels of all these parameters in OHA group. Conclusion: Our results conclude that supplementation of zinc improved the effectiveness of OHA and may be beneficial in decreasing blood glucose, TG, urinary albumin excretion and inflammation in diabetic nephropathy patients and thus reducing the risk of complications.

Advanced glycation end products and diabetic retinopathy

Studies have established hyperglycemia as the most important factor in the progress of vascular complications. Formation of advanced glycation end products (AGEs) correlates with glycemic control. The AGE hypothesis proposes that hyperglycemia contributes to the pathogenesis of diabetic complications including retinopathy. However, their role in diabetic retinopathy remains largely unknown. This review discusses the chemistry of AGEs formation and their patho-biochemistry particularly in relation to diabetic retinopathy. AGEs exert deleterious effects by acting directly to induce cross-linking of long-lived proteins to promote vascular stiffness, altering vascular structure and function and interacting with receptor for AGE, to induce intracellular signaling leading to enhanced oxidative stress and elaboration of key proinflammatory and prosclerotic cytokines. Novel anti-AGE strategies are being developed hoping that in next few years, some of these promising therapies will be successfully evaluated in clinical context aiming to reduce the major economical and medical burden caused by diabetic retinopathy.

Rhabdomyolysis and acute kidney injury in dengue fever

Rhabdomyolysis is a rare but potentially lethal complication of severe dengue fever. We present a case of 21-year-old man with fever, bodyache and black coloured and decreasing amount of urine. He was positive for NS1 (non-structural protein-1) antigen and IgM antibody for dengue. Platelet count was below 20×109/L and kidney function test was deranged. Urine was positive for myoglobin. The patient was managed emergently on conservative lines and improved in 10 days. Rhabdomyolysis should always be kept in mind in a patient with severe dengue, as its early detection and prompt management can prevent further progression to acute renal failure.

Reduction of microalbuminuria in type-2 diabetes mellitus with angiotensin-converting enzyme inhibitor alone and with cilnidipine

The aim of our study was to find out the antiproteinuric effect of enalapril angiotensin-converting enzyme (ACE inhibitor) alone or in combination with cilnidipine in patients with type-2 diabetes mellitus. The study was conducted on 71 patients with type-2 diabetes mellitus patients with hypertension and microalbuminuria. They were divided into two groups randomly as follows: Group I (enalaprilalone, n = 36) and Group II (enalapril with cilnidipine, n = 35). In both the groups, baseline 24 h urinary albumin was estimated and was repeated every 3 months upto 1-year. After 1-year follow-up, reduction in microalbuminuria was found to be greater in Group II. In Group I microalbuminuria came down by 25.68 ± 21.40 while in Group II it reduced by 54.88 ± 13.84 (P < 0.001). We conclude that in diabetic population, cilnidipine has an additive effect in microalbuminuria reduction over and above the well-proven effect of ACE inhibitors.

Prevalence of pulmonary artery hypertension in patients of chronic obstructive pulmonary disease and its correlation with stages of chronic obstructive pulmonary disease, exercising capacity, and quality of life

Background: Pulmonary arterial hypertension (PAH) is a complication of chronic obstructive pulmonary disease (COPD) in advance stages, and its presence indicates poor prognosis. Aims and Objective: The present study was design to know the prevalence of PAH in patients with COPD and its correlation with stages of COPD, exercising capacity, and quality of life. Materials and Methods: It is a cross-sectional prevalence study over a period of 1 year from August 2015 to July 2016. The study included 109 COPD patients, diagnosed by spirometry, and severity was determined according Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification criteria. Screening two-dimensional echocardiography was done to determine pulmonary arterial hypertension and exercising capacity assessed by 6 min walk test (6MWT) while the quality of life was assessed by St George respiratory Questionnaire for COPD (SGRQ-C) Questionnaires. Results: Out of 109 patients, PAH was present in 68 (62.4%) cases consisting of mild grade 41 (37.6%), moderate grade 11 (10.1%), and severe grade 16 (14.7%). In GOLD A stage, there were 20 cases of mild PAH and Stage B included 18 cases of mild and 3 cases of moderate PAH. Stage C had 3 cases of mild and 8 cases of moderate PAH while Stage D had 16 cases of severe PAH. In 6MWT, patients with severe grade PAH fail to perform the test while patients with mild to moderate PAH walked short distance. In SGRQ-C Questionnaires symptom, activity, impact, and total score were high with the severity of PAH. Conclusion: The prevalence of PAH in COPD was significant. Therefore, every COPD patient should be evaluated for PAH.

Relation of bone mineral density with homocysteine and cathepsin K levels in postmenopausal women

Background: Homocysteine (HCY) interferes with collagen cross-linking in bones and stimulates osteoclast activity. The activated osteoclasts secrete cathepsin K (CathK), a cysteine protease, in eminent quantity during bone resorption. Hyperhomocysteinemia may effect bone mineral density (BMD) through CathK. We, therefore, examined the relation between HCY and BMD along with CathK, 25-hydroxyvit-D (25[OH]D), intact parathyroid hormone (iPTH), and Vitamin B12. Materials and Methods: We recruited a total of 93 postmenopausal women between the age group of 45–60 years, attending the Endocrinology outpatient department at King Georges Medical University, Lucknow. BMD was done by DXA scan using Hologic QDR1000 system. Based on the WHO criteria, patients were segregated into three groups as follows; normal bone mass, osteopenia, and osteoporosis. All women underwent routine biochemical laboratory parameters, HCY, Vitamin B12, and CathK levels. Results: Among 93 postmenopausal women, 56% (52) had osteoporosis. Nineteen percent (18) had normal BMD (mean age, 53.22 ± 8.5 years) and 23 (25%) had osteopenia (mean age 52.86 ± 6.67 years). The mean age in the osteoporetic group was 56.2 ± 6.9 years. The median (interquartile range) levels of HCY in the three groups were 14.5 μmol/L (12.2–24.7), 15.05 μmol/L (12.1–19.9) and 13.2 μmol/L (10.3–17.0), respectively. CathK levels were similar in three groups 7.6 ng/ml (7.0–80.5), 8.3 ng/ml (7.3–8.5), and 8.6 ng/ml (7.2–8.9). Both HCY and CathK were found positively associated with serum phosphorus (r = 0.584, P < 2.01 and r = 0.249, P < 0.05, respectively). Levels of HCY positively correlate with PTH (r = 0.303, P < 0.01) and inversely with Vitamin B12 (r = −0.248, P < 0.05). No significant association was seen between CathK level and 25(OH) D, iPTH, serum calcium. Conclusion: Low bone mass by DXA is a significant problem in postmenopausal females. HCY and CathK do not reliably correlate with bone loss in postmenopausal women although phosphorus metabolism may play a role.

Pulmonary tubercular cavitory lesion: An unusual presentation in systemic lupus erythematosus

A 26-year-old women diagnosed as having lupus nephritis was managed with immunosuppressive therapy, which included cycles of Inj. Cyclophosphomide along with Inj. Mesna and Inj. Leprolide. After 1-month therapy, the patient developed moderate- to high-grade fever associated with cough and expectoration. Sputum examination was positive for acid-fast bacilli by modified Ziehl - Neelsen (ZN) staining technique. Chest skiagram Posterioanterior (PA) view and Computed tomography (CT) scan thorax depicted thick-walled cavity in right upper zone of lung with air-fluid level. Patient was managed with second-line antituberculosis drugs during hospitalization and was followed.

Abdominal lymphadenopathy – tuberculosis mimicking classy clinicoradiological features of hodgkin's disease

Abdominal lymphadenopathy is regularly encountered clinical entity and planning a management on likely diagnosis may prove disastrous. In the present case, clinical features with CT findings of massive diffuse paraaortic, mesenteric and splenic group of lymph nodes, mass at the head of the pancreas, encasement of portal vein, gross splenomegaly and ascites added with suggestion from bone marrow biopsy almost clinched the diagnosis in favour of Hodgkin’s disease. Biopsy, however turned the table topsy turvy by confirming these lymph nodes to be of tuberculous origin. Histopathology, thus remains a must tool of information to find a correct diagnosis as observed in this case. Abdominal Lymphadenopathy – Tuberculosis mimicking classy clinicoradiological features of Hodgkin’s Disease

Vesiculopustuloulcerative lesions in erythema nodosum leprosum as initial manifestation of leprosy

Erythema nodosum leprosum presenting as vesiculopustular lesions as initial manifestation of leprosy caused by Mycobacterium leprae is of rare occurrence and is very sparsely reported. We present a case of 24-year-old man with complaint of fever, inguinal lymphadenopathy, and vesiculopustular lesions over extremities and trunk. Slit skin smear from lesions showed acid-fast bacilli. Histopathological examination of the skin biopsy revealed granuloma with acid-fast bacilli. Patient was managed conservatively with multidrug therapy along with steroids and thalidomide and improved during hospital stay. Erythema nodosum leprosum expressing as initial manifestation of leprosy in form of vesiculopustular lesions is needed to be enlisted along with the other differential diagnosis presenting similarly.

Dengue myocarditis presenting with mitral valve involvement

We admitted a case of dengue fever who was positive for dengue serotype 2 in the Department of Medicine, King George′s Medical University (K.G.M.U.), Lucknow, Uttar Pradesh, India. The patient had developed erythematous rashes with thrombocytopenia and bleeding manifestation in the form of microscopic hematuria. While he was recovering from the illness, he developed a sudden onset of breathlessness. On examination, his chest was full of crepitation bilaterally and his x-ray was suggestive of pulmonary edema. His troponin T (Trop T) and prohormone brain natriuretic peptide (proBNP) levels were elevated. Two-dimensional echo showed global left ventricular (LV) hypokinesia with mitral regurgitation (MR) and tricuspid regurgitation (TR). A diagnosis of myocarditis was made and the patient was managed in an intensive care unit (ICU) setting. The patient recovered from the illness and after a follow-up period of 6 weeks, showed no residual cardiac abnormality.