Gopal Chandra Ghosh

Allergic Broncho Pulmonary Aspergillosis Complicated by Nocardiosis

We describe a 70-year-old male with a history of diabetes mellitus, hypertension, and asthma who presented with increasing breathlessness for 5 months. He was diagnosed to have allergic bronchopulmonary aspergillosis (ABPA) by serological and radiographic criteria. He was treated with steroids and itraconazole. After initial improvement, he developed fever with cough and mucopurulent sputum. X-ray chest revealed multiple cavities with air fluid level. Patient was treated with antibiotics without any response. Sputum was negative for acid fast bacilli (AFB). Sputum culture for bacteria and fungus did not reveal any significant growth; however a delayed growth of Nocardia was noted on fungal plates. Modified Ziehl Nelsen stain was positive for AFB. Patient was treated with cotrimoxazole. We discuss the serological and radiological criteria of ABPA, presentation and treatment of nocardia pulmonary infection and other possible causes of necrotizing pneumonia in immunocompromised settings.

RVX 208: A novel BET protein inhibitor, role as an inducer of apo A‐I/HDL and beyond

Low-density cholesterol (LDL) has been the prime target of currently available lipid-lowering therapies although current research is expanding the focus beyond LDL lowering and has included high-density cholesterol (HDL) also as the target. Bromo and extra-terminal (BET) proteins are implicated in the regulation of transcription of several regulatory genes and regulation of proinflammatory pathways. As atherosclerosis is an inflammatory pathway and studies showed that BET inhibition has a role in inhibiting inflammation, the concept of BET inhibition came in the field of atherosclerosis. RVX 208 is a novel, orally active, BET protein inhibitor and the only BET inhibitor currently available in the field of atherosclerosis. RVX 208 acts primarily by increasing apo A-I (apolipoprotein A-I) and HDL levels. RVX 208 has a novel action of increasing larger, more cardio-protective HDL particles. Post hoc analysis of Phase II trials also showed that RVX 208 reduced major adverse cardiovascular events (MACE) in treated patients, over and above that of apo A-I/HDL increasing action. This MACE reducing actions of RVX 208 were largely due to its novel anti-inflammatory actions. Currently, a phase III trial, BETonMACE, is recruiting patients to look for the effects of RVX 208 in patients with increased risk of atherosclerotic cardiovascular disease. So BET inhibitors act in multiple ways to inhibit and modulate atherosclerosis and would be an emerging and potential option in the management of multifactorial disease like coronary artery disease by inhibiting a single substrate. But we need long-term phase III trial datas to look for effects on real-world patients.

CSF ADA Determination in Early Diagnosis of Tuberculous Meningitis in HIV-Infected Patients

Tuberculous and Cryptococcal meningitis are common in HIV patients. A highly specific and sensitive rapid test for diagnosis of Tuberculous meningitis especially in setting of HIV is not available in developing countries where the burden of disease is high. We measured ADA (adenosine deaminase) levels using spectrophotometric method in the CSF of HIV patients with meningitis to differentiate Tuberculous meningitis from meningitis due to other causes. Kruskal-Wallis test was used to compare ADA values between tuberculous meningitis (TBM) and nontuberculous (non-TB) meningitis patients and a receiver-operating characteristic (ROC) analysis curve was drawn from these values. Levels of ADA in the CSF of patients with TBM were significantly higher than those in patients with meningitis due to other causes. CSF ADA level determination with a cut-off value of 6 IU/L was found to be highly specific and fairly sensitive test for the diagnosis of TBM in HIV positive patients.

Significance of pulmonary hypertension in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most prevalent hereditary cardiac disease characterized by the presence of left ventricular and/or septal hypertrophy in the absence of other underlying cardiac disorders. Patients of HCM have a broad range of clinical presentation from being asymptomatic to severely ill condition requires hospitalization and urgent management. Broadly, HCM is classified in two variants: obstructive and nonobstructive. The mainstay of diagnosis is through echocardiography. As HCM chiefly affect the left heart, pulmonary hypertension (PH) is an expected complication of this disease. Though the existence of PH in HCM is known for a long time, its clinical significance, underlying mechanism, and prognostic impact in HCM have been revealed by few recent studies. Specifically, studies have shown increased events of thromboembolism, atrial fibrillation, and heart failure in patients with HCM and PH. These studies elucidated the underlying mechanism of PH in HCM--a rise of pressure in the precapillary and postcapillary pulmonary vasculature. In addition to left ventricular involvement, studies have shown right ventricular involvement and the association of left and right ventricular dysfunction in these patients. Further, it has been shown that surgical intervention to reduce septal thickness improves survival in pharmacotherapy nonresponders and the presence of PH does not increase mortality in these patients. We present a comprehensive review exploring the prevalence, underlying mechanisms, and impact of PH on HCM.

Dengue fever with encephalitis: a rare phenomenon

The clinical profile and presentation of patients with dengue fever may differ from asymptomatic infection to the dreadful complications like dengue shock syndrome. However, neurological complications are very rare. Dengue encephalitis occurs by a direct involvement of central nervous system by the dengue virus which is an extremely rare complication. A 33-year-old man presented with fever, vomiting and severe headache. He had one episode of generalised tonic-clonic seizure followed by an altered sensorium on the day of admission to the hospital. The diagnosis of dengue fever was confirmed by dengue serology (IgM) and (NS1) antigen assay. MRI brain was suggestive of encephalitis. Thus, the patient was treated symptomatically and discharged in stable condition with minimal neurological deficit.

Red colour venous flow in the suprasternal view: a red flag sign

A 3-day-old full-term neonate, born by normal vaginal delivery, was presented with respiratory distress and mild cyanosis. His room air saturation in all four limbs was 84%. The clinical examination was unremarkable. Chest X-ray showed cardiomegaly and increased pulmonary vascular markings. Transthoracic echocardiography revealed 8 mm ostium secundum atrial septal defect (ASD) with bidirectional shunt and dilated right atrium and right ventricle with absence of individual pulmonary veins (PV) draining into left atrium (LA). Suprasternal view showed vertical vein (VV) which was recognised as a vessel lateral to LA with red-coloured …

Effectiveness and Safety of Inclisiran, A Novel Long-Acting RNA Therapeutic Inhibitor of Proprotein Convertase Subtilisin/Kexin 9

Low-density cholesterol (LDL-C) has a causal association with coronary artery disease and acute coronary syndromes (ACS). Statins have been found to reduce LDL-C, and many randomized trials have documented the significant role of statins in prevention and treatment of ACS. Treatment with statin therapy is associated with few shortcomings. A healthy percentage of patients initiated on statin, discontinue it within a year of initiation predominantly because of its daily dosing schedule. There is considerable variability in treatment response to statins and in some percentage of patients with high risk for ACS, satins are not enough to help reach the LDL-C goal necessitating the development of alternate LDL-C lowering therapies. Inclisiran a small interfering ribonucleic acid molecule inhibitor is helpful in sustained reduction of LDL-C. A single dose can decrease LDL-C for around 6 months, showed promising results in the phase II trials. In conclusion, here we reviewed the possibilities of Inclisiran as LDL-C reducing therapy and compared with currently available newer nonstatin LDL-C lowering therapies.

An infant with truncus arteriosus with situs inversus with single atrium: A case report

Truncus arteriosus is a rare heart defect comprising <1% of congenital cyanotic heart disease. Rarely it may be associated with single ventricle, but association with single atrium is very rare. We report a case of truncus arteriosus (Van Praag type A2) with single atrium and single ventricle. <Learning objective: In our case truncus arteriosus was associated with single atrium, single ventricle, and situs inversus which is rare and has not been reported in the literature.>.

Criss-cross heart: Transthoracic echocardiographic features

Objective To study the echocardiographic features of criss-cross heart (CCH), a congenital cardiac anomaly characterized by crossed ventricular inflow streams, in Indian patients. Methods In this retrospective observational study, all pediatric echocardiograms performed in a single tertiary care institution in South India over a three-year period were scrutinized for a diagnosis of CCH. Demographic, clinical and echocardiographic data were collected from patients’ medical records and echocardiographic database. Crossed ventricular inflow streams was identified when there was inability to visualize both atrio-ventricular valves in a single imaging plane in cardiac four chamber view. Results CCH was diagnosed in five patients from 10,500 pediatric echocardiographic studies. The age at diagnosis ranged from one month to 8 years. Cyanosis was present in all but one of the five cases. Crossed ventricular inflow streams was present by definition in all cases, whereas superior-inferior ventricular relationship was present in only three cases. All cases were associated with ventricular septal defects. Atrio-ventricular discordance was seen in three cases and concordance in two. Ventriculo-arterial discordance was seen in three cases, concordance in one and double outlet right ventricle in one. Three cases had pulmonary stenosis and the other two had pulmonary arterial hypertension. Straddling of AV valve was observed in four cases and hypoplastic aortic arch in one case. Conclusion CCH is an extremely rare congenital cardiac anomaly. Superior-inferior ventricular relationship often co-exists with CCH, but is not necessarily present in all cases. CCH requires early diagnosis because of its common association with diverse cardiac anomalies.

A dairy worker with fever and an abnormal echocardiogram

Description of the case A 38-year-old male presented with history of progressively increasing dyspnoea of 25 days duration. He gave history of low -grade fever associated with malaise and weight loss over the preceding 6 months. He worked in the dairy industry in the Middle East and returned to India owing to his illness. On clinical examination, he was found to be tachypneic and cachectic. Jugular venous pressure was raised with a prominent ‘a’ wave. There was a short early diastolic murmur over the aortic area. His blood investigations, including renal and liver function tests, were normal. Three sets of blood cultures were sterile. Two-dimensional trans-thoracic and trans-oesophageal echocardiography revealed thickened bicuspid aortic valve cusps, with moderate eccentric aortic regurgitation and an abnormal structure posterior to the left ventricular outflow tract and aorta (figure 1A–C). A small vegetation was seen attached to the fused right–left aortic cusp (supplementary figure 1). The patient was started on appropriate intravenous antibiotics and antifailure medications, and was referred for early surgical treatment. Figure 1 (A) Transthoracic echocardiography parasternal long axis view. (B) Transesophageal echocardiography (mid esophageal level) long axis view