Barkur Ananthakrishna Shastry

Acute ingestion of copper sulphate: A review on its clinical manifestations and management

Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical course of the copper sulphate intoxicated patient is often complex involving intravascular hemolysis, jaundice and renal failure. The treatment is mainly supportive. In severe cases methemoglobinemia needs treatment. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is done.

Blue vitriol poisoning: a 10-year experience in a tertiary care hospital.

Background and aim. Copper sulphate poisoning, while unusual in the West, is not rare in the Indian subcontinent, and mostly suicidal in intent. Unfortunately, data available on copper sulphate poisoning is limited. This study was planned to identify common presentations and complications of copper sulphate poisoning, and biochemical parameters that predict outcomes in these patients. Materials and methods. A retrospective analysis of 35 patients presenting with copper sulphate poisoning over a period of 10 years (2001–2010) was performed, based on review of their medical records. Paediatric cases and patients with concomitant poisoning with other substances were excluded. Clinical presentation, laboratory parameters, complications and treatment modalities were studied. Results. Of the 35 cases, 23 were females (65.71%). Mean age was 29.18 ± 10.77 years. Vomiting was the commonest symptom (85.71%) followed by diarrhoea (45.71%), epigastric pain (42.86%) and rectal passage of blood (31.43%). Fourteen (40%) patients had pre-existing psychiatric disease. Medical signs included pallor (37.14%) and icterus (37.14%). Major complications included hemolysis (68.57%), renal failure (51.43%), acute hepatitis (45.71%) and upper gastrointestinal bleed (40%). Mean serum copper at presentation was 104.53 ± 56.67 μg/dL; mean methemoglobin level was 9.59 ± 8.28%. Twenty-seven patients survived yielding a mortality rate of 22.9%. Peak serum aspartate and alanine aminotransferases were significantly lower (223.8 ± 247.3U/L, 66.3 ± 92.2U/L) in survivors compared to non-survivors (489.6 ± 374.0U/L, 192.9 ± 168.7U/L; p = 0.03, p < 0.01, respectively). Analysis by receiver operating characteristic (ROC) curve showed sensitivities of 100% and 85.7%, and specificities of 73.1% and 69.2%, respectively for peak serum alanine aminotransferase levels greater than 55 U/L, and peak serum aspartate aminotransferase levels greater than 234 U/L in predicting mortality. Conclusion. Copper sulphate is a potent poison that can involve multiple organ systems. Elevated levels of serum aspartate and alanine aminotransferases beyond the aforementioned values can identify patients at greater risk of mortality, allowing for institution of aggressive treatment.

Hydroxyurea Induced Perimalleolar Ulcers

Hydroxyurea (HU) is an antineoplastic drug commonly used to treat chronic myeloproliferative disorders. Common dermatological side effects include hyperpigmentation, scaling, erythema, alopecia, desquamation of face and hands. Leg ulceration following HU therapy is less common and very few cases have been reported so far. Objective of this paper is to increase the awareness of hydroxyurea induced leg ulcers which will aid in the early diagnosis and appropriate treatment. The first case was a chronic myeloid leukemia (CML) patient on HU 1.5 g/day for 5 yr, who had bilateral painful perimalleolar ulcers for 6 months. The second case was a CML patient on HU 1.5 g/day for 3 yr who developed bilateral lateral malleolar ulcers. Third case was a polycythemia vera (PV) patient on HU 1 g/day for 5 yr who presented with painful medial malleolar ulcer of 2 months. The last case of our report was an elderly PV patient on HU 1.5 g/day for 2 yr and presented with lateral malleolar ulcer which persisted on reducing the dose of HU. In all the 4 cases the ulcers healed on stopping HU. Our report confirms the association of chronic hydroxyurea therapy and perimalleolar ulcers which respond promptly after discontinuation of the drug. The heightened awareness among the physicians will promote early diagnosis and prompt relief from the agonizing ulcers.

Photobiomodulation by helium neon and diode lasers in an excisional wound model: A single blinded trial

Background: Application of different kinds of lasers in clinical and experimental studies causes photobiomodulation that works at localized cellular and humoral level on various biological systems. Increased numbers of fibroblasts, myofibroblast, and degranulation of mast cells have been the observed benefits post-irradiation. Objective: Was to find out the effect of irradiation with energy densities of 3.38 J/cm 2 , 8 J/cm 2 , and 18 J/cm 2 on animal tissue (albino wistar rats) in an excisional wound model and to assess changes in biochemical (hydroxyproline) and histopathological levels in excisional wound model. Materials and Methods: The animals were divided into 4 groups, which were labeled as L1, diode laser (18 J/cm 2 ), L2 Helium-neon (He-Ne, 8 J/cm 2 ), L3 diode laser (3.38 J/cm 2 ), and sham treatment for control was depicted by C, respectively. Histological and hydroxyproline analysis was performed on 7, 14, 21 days of post-wounding. One-way analysis of variance, ANOVA and Bonferroni′s multiple comparison tests were done for tissue hydroxyproline levels. Results: There was no significant increase in the hydroxyproline content (P < 0.005) when observed in study group and compared to controls. Whereas significant epithelizations was seen in group treated with He-Ne laser of intensity of 8 J/cm 2 . Conclusion: The experimental observations suggest that low intensity helium-neon laser of 8 J/cm 2 intensity facilitated photo stimulation by tissue repair, but failed to show significant tissue hydroxyproline levels in excisional wound model.

Melioidosis presenting with mediastinal lymphadenopathy masquerading as malignancy: a case report

IntroductionMelioidosis, endemic in Thailand and in the Northern Territory of Australia is an emerging infectious disease in India which can present with varied forms. A case of melioidosis, presenting as a rare anterior mediastinal mass which can masquerade as malignancy or tuberculosis, is described here. With treatment, our patient initially showed an increase in the size of mediastinal node and development of new submandibular node.. To the best of our knowledge, this phenomenon has not been documented in the literature and the same is highlighted in this case report.Case PresentationA 43-year-old Asian man with diabetes presented with fever, loss of appetite, weight loss for one month and painful swelling below his left mandible for five days. An examination revealed an enlarged left submandibular lymph node and bilateral axillary lymph nodes. A chest X-ray showed mediastinal widening. Computed tomography of his thorax showed a lobulated heterogeneously enhancing anterior mediastinal mass encasing the superior vena cava suggestive of malignancy. An excision biopsy of the lymph node showed granulomas suggestive of tuberculosis but bone marrow culture and lymph node aspirate culture grew Burkholderia pseudomallei. He was treated with parenteral ceftazidime and amoxicillin-clavulanic acid. During the course of treatment, he developed an enlargement of the submandibular lymph node on the opposite side. It gradually subsided with the continuation of therapy orally with a combination of cotrimoxazole and doxycycline for six months. A repeat computed tomography chest scan showed resolution of the mediastinal mass.ConclusionMelioidosis can present as a mediastinal mass that mimics tuberculosis or malignancy. During the initial phase of treatment of melioidosis, the appearance of new lymph nodes or an increase in the size of the existing lymph nodes does not mean treatment failure. Inexperienced clinicians may consider this as treatment failure and may switch treatment. To the best of our knowledge, this is the first report documenting this phenomenon in melioidosis cases.

False-Positive Widal In Melioidosis

Enteric fever is endemic in this part of the world, and Widal test is one of the time-honored laboratory tests that are being used for years to diagnose the disease. On the other hand, melioidosis is a newly emerging disease from this region, which is most often misdiagnosed or underdiagnosed by clinicians. It is well accepted that false-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. Three cases of high titers of Widal test are described, where melioidosis was the actual diagnosis in every occasion and was never suspected until diagnosed microbiologically. All the patients had shown a partial response to ceftriaxone. Blood and pus cultures grew Burkholderia pseudomallei, whereas Salmonella typhi was not isolated from blood in any patient. With appropriate antibiotics, the patients showed clinical and microbiological improvement with lowering of Widal titers. These 3 cases show that high Widal titer in any patient may mislead the diagnosis of melioidosis, and further laboratory workup should always be done to rule out melioidosis, especially in cases with nonresponsiveness to treatment.

Parietal bone osteomyelitis in melioidosis.

We report a case of a 55-year-old man with uncontrolled diabetes who presented with pneumonia. During his hospital stay his clinical status worsened and he had a focal seizure. MRI showed central nervous system involvement and parietal bone osteomyelitis. As the patients blood culture and endotracheal aspirate grew Burkholderia pseudomallei, melioidosis was diagnosed. He was treated with meropenem after failure to respond to ceftazidime. He gradually improved over a period of 4 weeks and was discharged. Early diagnosis and therapy resulted in improved outcome.

Successful treatment of right-sided native valve methicillin-resistant Staphylococcus aureus endocarditis and septicaemia with teicoplanin and rifampicin: A case report

Vancomycin is the drug of choice in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infection. However, the presence of certain clinical complications like renal failure alters vancomycin pharmacokinetics, leading to drug accumulation and toxicity. This highlights the need to identify an effective substitute for treating MRSA infections when vancomycin cannot be used. We report the case of a 57-y-old Indian male diagnosed with tricuspid valve endocarditis with septicaemia and a right upper lobe cavity caused by MRSA. The patient also presented with renal failure, which precluded the use of vancomycin for treatment. A 6-week regimen of teicoplanin and rifampicin was used instead, and the infection was successfully treated. This case report provides evidence of the effectiveness of teicoplanin and rifampicin in the treatment of MRSA bacteraemia in situations where the use of vancomycin is contraindicated.

Closure of non-healing chronic ulcer in Klippel–Trenaunay syndrome using low-level laser therapy

A 69-year-old man diagnosed with Klippel–Trenaunay syndrome (KTS) reported to the physiotherapy outpatient clinic with the complaint of a non-healing ulcer over the right medial malleolus, for a 6-month duration, that was non-granulating and had moderate pus discharge with foul odour at initial assessment. There was a decrease in scores of the Pressure Ulcer Scale of Healing, a significant increase in granulation tissue, a decrease in the amount of discharge and foul odour along with complete closure of the chronic wound after irradiation with a light-emitting diode (LED). This is a novel case study analysing the possible effect of a helium–neon laser and LEDs on non-healing chronic ulcers associated with KTS, where the complete closure of the chronic ulcer that was initially not responsive to standard medical care was observed.

Elizabethkingia meningoseptica: emerging multidrug resistance in a nosocomial pathogen

A 46-year-old male patient presented with complaints of burning micturition for 2 days. Initial history, physical examination and laboratory investigations were consistent with the diagnosis of congestive cardiac failure (CCF) and concomitant urinary tract infection. CCF was treated with diuretics and a urine culture/sensitivity (C/S) was sent which returned growing Elizabethkingia meningoseptica resistant to all tested drugs. Intravenous cefotaxime which had been started empirically 3 days earlier was withheld at this point, and a repeat urine C/S was sent revealing resistance to all tested drugs (including reserved drugs) barring minocycline. The patient was treated with oral minocycline for 14 days after which he was symptomatically better with sterile urine. The patient was subsequently discharged.