Atul Sachdev

Disseminated cysticercosis: a case report and review of the literature.

IntroductionCysticercosis is a common tropical disease. One of the uncommon manifestations of cysticercosis is its disseminated form.Case presentationWe report an immunocompetent patient with disseminated cysticercosis, who had involvement of the brain, subcutaneous tissues, skeletal muscles, right orbit and thyroid gland. In addition, this patient developed a serum sickness which responded to therapy.ConclusionWide spread dissemination is a rare complication of cysticercosis. A planned approach to therapy is required.

Autosomal dominant polycystic kidney disease with diffuse proliferative glomerulonephritis - an unusual association: a case report and review of the literature

IntroductionAutosomal dominant polycystic kidney disease is an inherited disorder that is characterized by the development and growth of cysts in the kidneys and other organs. Urinary protein excretion is usually less than 1 g/24 hours in autosomal dominant polycystic kidney disease, and an association of nephrotic syndrome with this condition is considered rare. There are only anecdotal case reports of autosomal dominant polycystic kidney disease associated with nephrotic syndrome, with focal segmental glomerulosclerosis being the most commonly reported histopathological diagnosis. Nephrotic-range proteinuria in the presence of autosomal dominant polycystic kidney disease, with or without an accompanying decline in renal function, should be investigated by open renal biopsy to exclude coexisting glomerular disease. To the best of our knowledge, this is the first case of autosomal dominant polycystic kidney disease with histologically proven diffuse proliferative glomerulonephritis presenting with nephrotic-range proteinuria. No other reports of this could be found in a global electronic search of the literature.Case presentationWe report the case of a 35-year-old Indo-Aryan man with autosomal dominant polycystic kidney disease associated with nephrotic syndrome and a concomitant decline in his glomerular filtration rate. Open renal biopsy revealed diffuse proliferative glomerulonephritis. An accurate diagnosis enabled us to manage him conservatively with a successful outcome, without the use of corticosteroid which is the standard treatment and the drug most commonly used to treat nephrotic syndrome empirically.ConclusionDespite the reluctance of physicians to carry out a renal biopsy on patients with autosomal dominant polycystic kidney disease, our case supports the idea that renal biopsy is needed in patients with polycystic kidney disease with nephrotic-range proteinuria to make an accurate diagnosis. It also illustrates the importance of open renal biopsy in planning appropriate treatment for patients with autosomal dominant polycystic kidney disease with nephrotic-range proteinuria. The treatment for various histological subtypes leading to nephrotic syndrome is different, and in this modern era we should practice evidence-based medicine and should avoid empirical therapy with its associated adverse effects.

Neuroendocrine Tumors of the Ampulla of Vater: Presentation, Pathology and Prognosis

CONTEXT Neuroendocrine tumors of the pancreatic ampulla are uncommon. The final diagnosis is based on histology, and at times, it may be difficult to diagnose them pre-operatively since they present with a similar clinical picture to adenocarcinomas of this region. OBJECTIVE To identify neuroendocrine tumors of the ampulla, as well as their presentation and management. DESIGN A retrospective review of patients treated at a tertiary care institute was performed over a six-year period from 2005 to 2010. PATIENTS Cases with periampullary cancers were investigated. MAIN OUTCOME MEASURES The case records were scrutinised for the clinical presentation, management and outcomes. RESULTS A total of 4 cases (7.7%) of neuroendocrine tumors of the ampulla were identified from 52 patients with periampullary lesions, at a mean age of presentation of 49 years. The common mode of presentation was progressive jaundice (3 of 4 patients); pancreaticoduodenectomy was performed in 3 patients. One patient underwent palliative endoscopic stenting for metastatic disease. On histopathology, 2 of the patients had poorly differentiated (neuro)endocrine carcinoma (high grade), and 2 had well differentiated (neuro)endocrine carcinoma (1 low grade and 1 intermediate). All the tumors stained positively with chromogranin A. The patients who underwent pancreaticoduodenectomy are on regular follow-up and remain free of disease. CONCLUSIONS Neuroendocrine tumors of the ampulla are distinct entities presenting clinically with jaundice. They stain positive with chromogranin A on histopathology. Pancreaticoduodenectomy should be performed as it is associated with good outcome.

Evaluation of aspiration cytology of the liver space occupying lesions by simultaneous examination of smears and cell blocks.

This study was undertaken to compare the efficacy of cytologic smears and histological sections from cell blocks in diagnosis of space occupying lesions (SOLs) of the liver and to classify the lesions on the basis of combined cytohistologic diagnosis. The study was conducted on 50 patients who had radiologically detected SOL/SOLs in the liver and ultrasound‐guided fine needle aspiration of liver was done. In all the cases, both smears and cell blocks were made. Forty‐seven cases were diagnosed as malignant and three as benign on both cytologic smears and cell blocks. Hepatocellular carcinoma was diagnosed in 8 (16%) cases and metastasis in 39 (78%) cases. The subtyping of malignancy could not be done on 11 (22%) cytologic smears and 8 (16%) cell block sections. However, on combined cytohistologic correlation, 17 (34%) out of these 19 (38%) cases could be subtyped. Sensitivity of cytologic smears and cell blocks in subtyping of malignancy was 72.3% and 82.9%, respectively. Combined cytohistologic diagnosis was found to be significantly better than isolated cytologic and cell block diagnosis (P ≤ 0.05). To conclude, FNA of the SOLs of the liver is an effective procedure for diagnosing malignancy. However, cytological examination alone may fail to pinpoint the type of the tumor. Concomitant examination of cell block not only confirms the malignancy but also helps in subtyping it. Diagn. Cytopathol. 2009.

Wasp sting associated with type 1 renal tubular acidosis

Wasp stings are a common day occurrence in tropical countries. Their venom contains a wide array of amines, peptides and enzymes, consisting of low molecular weight compounds such as serotonin, histamine, acetylcholine and several kinins that mediate direct toxic effects. Enzymes such as hyaluronidase and phospholipases allow the venom to spread. Generally, these stings cause local reactions that include immediate pain, wheal and flare reaction, which resolve within a few hours. Rarely, these reactions can cause systemic manifestations, organ dysfunction and even death. We describe one such extremely unusual presentation in which a wasp sting was associated with type 1 (distal) renal tubular acidosis (RTA). A 24-year-old male college student from North–West India presented with sudden onset weakness in all four limbs 9 h following a wasp sting on the face. As an immediate measure, a local practitioner administered intravenous chlorpheniramine 25 mg and hydrocortisone 100 mg. The patient denied any history of vomiting, diarrhoea, dry eyes or mouth, dental caries, rash, polyarthritis, fatigue, palpitations, breathlessness, ulcers, blood transfusions, jaundice, weight loss, heat intolerance, diuretic use, hypertension, deafness, pathological fractures or recent surgery. His past history was unremarkable and there was no history of similar complaints in the family. He did not have any addictions and there was no history of exposure to heavy metals. General physical examination revealed a well-built male with the heart rate of 96 bpm, blood pressure of 110/70 mm Hg and respiratory rate of 18/min. No physical abnormalities were noticed. Neurological examination revealed flaccid quadriparesis (Power III/V) with elicitable deep tendon jerks in all four limbs. There was no sensory, cranial nerve or cerebellar involvement. The remainder of the systemic examination was unremarkable. Haematological investigations showed haemoglobin 140 g/L, total leucocyte count 7×109/L, platelets 150 × 109/L and ESR 4 mm after 1 h by the Westergren method with a normal peripheral

Prevalence and determinants of use of potentially inappropriate medications in elderly inpatients: A prospective study in a tertiary healthcare setting

To determine the prevalence and predictors of potentially inappropriate medications (PIM) prescribing in elderly inpatients using the modified American Geriatrics Society (AGS) updated Beers criteria 2012 and comparing it with the Beers criteria 2003.

Drug-drug interactions and their predictors: Results from Indian elderly inpatients

Background In view of the multiple co-morbidities, the elderly patients receiving drugs are prone to suffer with drug interactions since they receive a greater number of drugs. Objective The study was undertaken to determine the prevalence of drug interactions, as well as their predictors. Methods The prescriptions of a total of 1510 inpatients were collected prospectively for 1.5 years from inpatients wards of public tertiary care teaching hospital. All the prescriptions were checked for drug interactions using the Micromedex® Drug-Reax database-2010 and Stockley’s Drug Interactions. Regression analyses sought to determine predictors for the drug interaction. Results The patients, with the average age of 67.2 ±0.2 years, were prescribed an average of 9.15 ±0.03 medications. It was found that out of 1510 prescriptions of inpatients, 126 (8.3%) prescriptions had one or more than one drug interaction. All the identified interactions were severe in nature. The top most interacting drugs were acetylsalicylic acid and anticoagulant (n=59). The second top most interacting drug combination was clopidogrel and proton pump inhibitors (n=51). The most commonly involved drugs in interactions were C (cardiovascular system) and A (alimentary tract and metabolism). Using multivariate binary logistic regression, multiple drugs (Odds Ratio=4.5; 95% Confidence Interval: - 2.38 -9.47) and multiple diagnoses (Odds Ratio=2.6; 95%CI: -1.40 -5.57) were found to be significant predictors for drug interaction. Conclusions The results of this study substantiate the occurrence of severe drug interactions among Indian elderly inpatients. In order to provide safer pharmaceutical care, the active involvement of clinical pharmacists is a potential option.

Measurement of adult antimicrobial drug use in tertiary care hospital using defined daily dose and days of therapy.

Widespread overuse and inappropriate use of antimicrobial drugs continues to fuel an increase in antimicrobial resistance and leads to consequent treatment complications and increased healthcare costs. In the present study we aimed to describe antimicrobial drug consumption and predictors and to identify potential targets for antimicrobial stewardship. This was a prospective observational study conducted at adult medicine wards of tertiary care teaching hospital over the period of five months. Antimicrobial drug consumption was measured using days of therapy per 1000 patient days and defined daily dose per 1000 patient days. Additionally, predictors of multiple antimicrobial prescribing were also analyzed. Seven hundred thirty patients were screened and 550 enrolled, receiving 1,512 courses of antimicrobial therapy, mainly intravenously (66%). Most frequently prescribed agents were artesunate (13%), ceftriaxone (11%) and metronidazole (10.5%). Overall consumption was 1,533 days of therapy per 1000 patient days and was mainly attributed to antibiotics (98.3%) for empirical therapy (50%). Median days of antimicrobial drugs prescribing were 3 (inter quartile range 2-5). Most commonly consumed antimicrobials were ceftriaxone (31%, 248.8 g) and artesunate (26%, 29 g). Antimicrobials contributed to 72.5% expense of the total incurred. Multivariate analysis reveals that younger patients (≥45 years) (odds ratio: 1.59, 95% CI 1.14-2.21) were more likely and absence of comorbidities (odds ratio: 0.58, 95% CI 0.42-0.79) and shorter hospital stay (≥6 days)(odds ratio: 0.44, 95% CI 0.32-0.60) were associated with less likelihood of prescribing multiple antimicrobial drugs. Estimating antimicrobial drugs use by defined daily dose method will remain open to criticism because the prescribed dosage is not often in agreement with the “usual” daily dose, which depends on location of and susceptibility of pathogenic organisms and metabolic status of the patient.

Touraine–Solente–Gole’ syndrome

Touraine–Solente–Gole’ syndrome, also known as pachydermoperiostosis or primary hypertrophic osteoarthropathy is a rare familial disorder generally seen in males. Although it presents with characteristic morphological and radiological features, this is an uncommon diagnosis and is entertained only once other causes of secondary hypertrophic osteoarthropathy are carefully excluded.

Comparison of Cytohistologic Techniques in Diagnosis of Gastroesophageal Malignancy

OBJECTIVE To evaluate the diagnostic performance of various endoscopic cytologic techniques, namely, brushing cytology, touch smear cytology and crush cytology, and comparison with concurrent biopsy results in diagnosis of gastroesophageal malignancy. STUDY DESIGN This prospective study was conducted on 100 patients, with 78 clinically suspected cases of esophageal malignancy and 22 cases of gastric malignancy. RESULTS The diagnostic accuracy of touch smear in esophageal malignancy was significantly higher (94.12%) than brushing and crush smears (89.71% each), and endoscopic biopsy had the diagnostic accuracy of 88.24%. The diagnostic accuracy of combined brushing and biopsy was 100%; it was 97.06% for touch smears combined with biopsy. In comparison, the diagnostic accuracy in gastric malignancy was 75% for brushing alone, which was significantly lower than touch smear (87.5%) and endoscopic biopsy (87.5%). The diagnostic yield for crush smear was 81.25%. A combination of touch smears and biopsy had a diagnostic yield of 100%; it was 93.75% for combined brushings and biopsy. CONCLUSION A combination of cytohistologic techniques resulted in a statistically significant increase in the diagnostic yield of gastroesophageal malignancies and thus cytologic techniques may act as adjunct to biopsy histology to increase the diagnostic efficiency.