Dipanjan Bandyopadhyay

Etiological study of fever of unknown origin in patients admitted to medicine ward of a teaching hospital of Eastern India

Background: In a developing country, infectious disease remains the most important cause of fever, but the noncommunicable diseases, like malignancy, are fast becoming important differential diagnoses. An important clinical problem is the cases labeled as fever of unknown origin (FUO), which often evade diagnosis. Objective: The present study was undertaken to find the cause of FUO in a tertiary care hospital of eastern India. Materials and Methods: This is a prospective study of inpatients, with regard to both clinical signs and investigations. Results: The main diagnosis in the end was tuberculosis, closely followed by hematological malignancy. A substantial number of cases remained undiagnosed despite all investigations. The provisional diagnosis matched with the final in around two thirds of the cases. While for younger patients leukemia was a significant diagnosis, for older ones, extra-pulmonary tuberculosis was a main concern. Interpretation: In India, infectious disease still remains the most important cause of fever. Thus the initial investigations should always include tests for that purpose in a case of FUO. Conclusion: Geographic variations and local infection profiles should always be considered when investigating a case of FUO. However, some of the cases always elude diagnosis, although the patients may respond to empirical therapy.

Multiple Sclerosis like Demyelination in Early HIV Infection-A Rare Presentation: Case Report and Literature Review

A 35 year-old male presented with left sided weakness for past 3 months, along with progressive deterioration in higher mental faculties, vision and audition. Clinical and investigational information suggested the diagnosis of an acute demyelination involving various areas of the brain. He was seropisitive for HIV and had good cellular immunity at the time of our assessment. We present this case to highlight the association of Multiple Sclerosis (MS) with HIV, either during seroconversion or early during course of this infection.

Therapeutic effects of nandrolone and testosterone in adult male HIV patients with AIDS wasting syndrome (AWS): a randomized, double-blind, placebo-controlled trial.

Abstract Purpose: We aimed to compare therapeutic effects of intramuscular (IM) nandrolone decanoate and IM testosterone enanthate in male HIV patients with AIDS wasting syndrome (AWS) with placebo control. Methods: In this randomized, double-blind, placebo-controlled, 12-week trial, 104 patients with AWS who satisfied our inclusion criteria were randomly allotted in a 2:2:1 ratio to the 3 intervention groups: nandrolone, testosterone, and placebo. We administered 150 mg nandrolone and 250 mg testosterone (both IM, biweekly). The primary outcome measure was a comparison of absolute change in weight at 12 weeks between the nandrolone decanoate, testosterone, and placebo groups. Results: Intent-to-treat analysis was done. The nandrolone group recorded maximum mean increase in weight (3.20 kg; post hoc P < .01 compared to placebo). Body mass index (BMI) of subjects in the nandrolone group had a significantly greater increase (mean = 1.28) compared to both testosterone (post hoc P < .05) and placebo (post hoc P < .01). Waist circumference and triceps skinfold thickness of patients on nandrolone showed similar results. Nandrolone also ensured a better quality of life. Patients with low testosterone level (<3 ng/mL) benefited immensely from nandrolone therapy, which increased their weight and BMI significantly compared to placebo (P < .05). Conclusion: Our trial demonstrates the superior therapeutic effects of nandrolone in male AWS patients, including the androgen deficient.

Multiorgan involvement due to cytomegalovirus infection in AIDS

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in todays era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

Pancytopenia with hemophagocytic syndrome associated with histoplasmosis in acquired immunodeficiency syndrome: description of 2 case studies and literature review.

Two cases of haemophagocytic syndrome (HPS) due to histoplasmosis in patients with the acquired immunodeficiency syndrome (AIDS) are described in our case studies. Both the patients presented with pancytopenia and the bone marrow aspirate showed features suggestive of haemophagocytosis and the presence of intracellular inclusions were compatible with Histoplasma capsulatum. Haemophagocytic syndrome due to disseminated histoplasmosis should be included in the differential diagnosis of pancytopenia in patients with AIDS, though it is a rare clinical entity.

A single fatal dose of olanzapine

Sir, A 52-year male presented with acute onset clouding of consciousness, rigidity, diaphoresis, urinary incontinence, and myoclonic jerks. He had recently developed a stress induced mood disturbance for which he was prescribed olanzapine. He had consumed a single 5 mg dose of the drug on the previous morning. Two hours post admission he developed high rise of temperature with further deterioration of sensorium. Neurological examination revealed a Glasgow coma scale score of 6, ‘lead-pipe’ rigidity, generalized myoclonus, and brisk deep tendon reflexes. The serum creatinine phosphokinase (CPK) level was 8,240 U/L, (Normal 60-400 U/L) and urine was positive for myoglobin. We diagnosed the case as neuroleptic malignant syndrome, discontinued olanzapine and initiated bromocriptine and clonazepam. His serum iron level was 18mg/dl. Serial CPK estimation showed a gradual normalization over the next eight days but there was little improvement in his sensorium even one month after CPK normalization. Prolonged recumbence resulted in multiple pressure sores and he eventually succumbed to aspiration pneumonia eight weeks after his admission.

Non tuberculous mycobacteria and toxoplasma co-infection of the central nervous system in a patient with AIDS

New-onset seizures are frequent manifestations in patients infected with Human Immunodeficiency Virus (HIV). We describe the clinical and radiological findings in an 25yr old AIDS patient presenting with new onset seizures as the primary manifestation of cerebral toxoplasmosis and Non Tuberculous Mycobacterial [NTM] co-infection. Cranial computed tomography showed a subtle ventricular dilatation whereas magnetic resonance imaging disclosed prominent temporal horn. Toxoplasma tachyzoites and rapidly growing mycobacteria were recovered from CSF. Seizures were complex partial in nature and refractory to antiepileptic therapy.

Mitochondrial myopathy associated with myasthenia gravis in a young man

An 18-year-old man presented with progressive weakness of proximal muscles with prominent diurnal variation for 3 months. He had bilateral ptosis since his childhood without diurnal variation or double vision. Neurological examination showed involvement of levator palpebrae superioris and lateral rectus muscles bilaterally. The plasma glucose after 75 gm glucose load was 302 mg/dL. The electrophysiological study revealed myopathic pattern and a decremental response in repetitive nerve stimulation. The plasma lactate was elevated and the muscle biopsy showed numerous ragged-red fibers. Serum acetylcholine receptor antibody assay was positive. We diagnosed myasthenia gravis with mitochondrial myopathy.

Headache in a Case of Rhupus Syndrome

We report a case of Rhupus with secondary anti‐phospholipid syndrome who presented with headache and papilloedema due to cerebral venous thrombosis. We propose that an increased awareness about the condition and meticulous investigation of headaches in lupus can avert catastrophic outcomes.