Dj Christopher

Addition of second-line steroid sparing immunosuppressants like mycophenolate mofetil improves outcome of Immunoglobulin G4-related disease (IgG4-RD): a series from a tertiary care teaching hospital in South India

IgG4-related disease (IgG4-RD) is a systemic fibro-inflammatory disease. This disease may be associated with elevated serum and tissue IgG4 levels. Early treatment prevents fibrosis and organ damage. We retrospectively studied the clinicopathologic correlation and outcome of treatment in IgG4-RD. This single-center retrospective study was done using electronic records of patients subjected to assay of serum IgG4 levels in our laboratory by nephelometry. There were 473 patients with suspected IgG4-RD. Of them, 41 patients fulfilled comprehensive diagnostic criteria for IgG4-RD and 432 had diseases other than IgG4-RD. Clinical and histopathological data including tissue IgG4/IgG ratio, other relevant laboratory findings as well as management data of 41 patients with IgG4-RD were analyzed. There were 29 males and 12 females with mean age of 44.1xa0±xa02.19xa0years. Thirteen patients had definite, 19 had probable and 9 had possible IgG4-RD. Male predominance, multiple organ involvement and IgG4 responder Index were significantly higher in definite IgG4-RD as compared to probable and possible IgG4-RD. Serum IgG4 level was elevated in 37 patients (90.2%). Glucocorticoids were used in 35 patients (85.4%) and second-line immunosuppressive agent in 23 patients (65.7%). Of the 21 patients on follow-up, 19 (90.7%) had clinical improvement at the first follow-up visit. Nine (90%) out of the ten patients who were assessed by IgG4 responder index, also had shown improved score with treatment. Patients with IgG4-RD in our series showed favorable responses to treatment with glucocorticoids and addition of steroid sparing immunosuppressive agents (mainly mycophenolate mofetil) helped successful tapering of steroids, while maintaining the improvement.

Rare cause of paradoxical worsening of pleural effusion in a patient with tuberculosis

A 33-year-old patient, Known case of chronic kidney disease on maintenance dialysis presented with complaints of low-grade fever and weight loss of 2 months duration. Computed tomography (CT) revealed bilateral mild pleural effusion with significant mediastinal and abdominal adenopathy. CT-guided fine-needle aspiration cytology of abdominal lymph nodes and bone marrow culture was suggestive of tuberculosis. The patient was started on four drug anti-tubercular therapy, post 6 weeks of initiation he developed new onset fever and chest X-ray revealed moderate right pleural effusion. Diagnostic thoracocentesis was suggestive of chylothorax. To the best of our knowledge, this is the first case report of chylothorax due to the paradoxical reaction in the HIV-negative tuberculous patient.

Cannonball shadow in the lungs and pulmonary embolism in a young man

A 20-year-old non-smoking man presented with a history of chest pain, cough, loss of weight and appetite for a 3-month duration. Prior to presentation, he was diagnosed at a local hospital as having pneumonia and was treated with oral and intravenous antibiotics. Since the patients symptoms did not abate with treatment, he was referred to our centre for further management.nnOn physical examination, his vital signs were within normal limits. He was not in obvious distress. There was a hard right-sided testicular swelling. His left testis was normal in consistency. There was no evidence of a hydrocele. The rest of the systemic examination was unremarkable.nn### Laboratory findingsnnHis blood counts and routine serum biochemistries were normal. His serum lactate dehydrogenase (LDH) was elevated at 3492u2005IU/L (normal up to 160u2005IU/L), β-human chorionic gonadotropin (β-HCG) was 89.29u2005mIU/mL (normal up to 5) and α-fetoprotein was14u2005IU/mL (normal up to 5.5). Serum antineutrophilic antibodies were not detected. The Mantoux test and sputum smear and culture for Mycobacterium tuberculosis bacilli were negative. His chest X-ray revealed …

A rare cause of ventilatory failure in a patient with post-traumatic intracranial hemorrhage

High minute ventilation is required to lower intracranial pressures in patients with intracranial bleed. Respiratory acidemia consequent to ventilatory difficulty is dangerous in such patients as it further raises intracranial tension. We describe such a case. A 24-year-old man had to be intubated and mechanically ventilated after he met with a road traffic accident and sustained extensive maxillofacial injuries and intracranial bleed. A tooth was accidentally aspirated in this injury and progressively resulted in left lower lobe collapse, pneumomediastinum, and consequent difficult ventilation. Under video bronchoscope guidance, the tooth was removed with grasping forceps. Pneumomediastinum temporarily increased after the tooth removal, but by 12 h postextraction, resolution of both the pneumomediastinum and left lower lobe collapse was observed. There was a 17 h delay postadmission before the cause of ventilatory failure was realized. Aspiration of foreign bodies, in general, and teeth, in particular, should be actively looked for in patients with ventilatory difficulties in the post-trauma setting.