Imran Rizvi

Complications associated with Plasmodium vivax malaria: a retrospective study from a tertiary care hospital based in Western Uttar Pradesh, India.

BACKGROUND Plasmodium vivax (p. vivax) malaria was traditionally considered as benign tertian malaria, however, recent studies have pointed out that p. vivax have potential to cause all severe complications previously attributed to p. falciparum infection only. The aim of this report is to study the incidence of various clinical and biochemical complications associated with severe p. vivax malaria. METHODS A retrospective analysis was performed on all patients with p. vivax malaria admitted to our center between January 2009 and December 2011. Severe malaria was defined as per World Health Organization (WHO) criteria. Clinical and laboratory parameters were recorded. Patients with evidence of p. falciparum, mixed malarial infection and chronic systemic diseases were excluded from the study. RESULTS Sixty-two patients met the criteria for severe malaria during the study period. The complications observed were Hepatic dysfunction in 18 (29%), renal dysfunction in 13 (21%), cerebral malaria in 10 (16.1%), acute respiratory distress syndrome (ARDS) in 6 (9.7%), shock in 10 (16.1%), severe anemia in 16 (25.8%), thrombocytopenia in 35 (56.5%), and hypoglycemia in 3 (4.8%) patients. Three mortalities were observed. CONCLUSIONS P. vivax has immense potential to cause life threatening complications and even death, more research is required to understand the exact pathogenesis of various complications encountered in vivax malaria.

Correlation between serum neuron specific enolase and functional neurological outcome in patients of acute ischemic stroke

Context: The use of biomarkers to predict stroke prognosis is gaining particular attention nowadays. Neuron specific enolase (NSE), which is a dimeric isoenzyme of the glycolytic enzyme enolase and is found mainly in the neurons is one such biomarker. Aims: This study was carried out on patients of acute ischemic stroke with the aims to determine the correlation between NSE levels on the day of admission with infarct volume, stroke severity, and functional neurological outcome on day 30. Materials and Methods: Seventy five patients of acute ischemic stroke admitted in the Department of Medicine were included in the study. Levels of NSE were determined on day 1 using the human NSE ELISA kit (Alpha Diagnostic International Texas 78244, USA). Volume of infarct was measured by computed tomography (CT) scan using the preinstalled software Syngo (version A40A) of Siemens medical solutions (Forchheim, Germany). Stroke severity at admission was assessed using Glasgow coma scale (GCS) and functional neurological outcome was assessed using modified Rankin scale (mRS) on day 30. Statistical Analysis Used: Statistical analysis was performed using the SPSS software for windows version 15.0 (SPSS). Results: A positive correlation was found between concentration of NSE on day 1 and infarct volume determined by CT scan (r = 0.955, P < 0.001). A strong negative correlation was found between GCS at presentation and concentration of NSE on day 1 (r = −0.806, P < 0.001). There was a positive correlation between NSE levels at day 1 and functional neurological outcome assessed by mRS at day 30 (r = 0.744, P < 0.001). Conclusions: Serum levels of NSE in first few days of ischemic stroke can serve as a useful marker to predict stroke severity and early functional outcome. However, larger studies with serial estimation of NSE are needed to establish these observations more firmly.

Widespread Intracranial Calcification, Seizures and Extrapyramidal Manifestations in a Case of Hypoparathyroidism

Hypoparathyroidism can present with neurological complaints like seizures, parasthesias, depression, psychosis, extrapyramidal manifestations and features of raised intracranial pressure. Hypoparathyroidism and pseudohypoparathyroidism are the most common causes of pathological basal ganglia calcification. A 50 year male presented with generalized seizures and extrapyramidal features like tremors and rigidity. Investigations revealed that he had hypocalcemia, hyperphosphatemia and very low PTH levels, CT scan of head showed calcification of bilateral basal ganglia, cerebellum and subcortical white matter of frontal and parietal lobes. He showed remarkable recovery on restoration of normal serum calcium levels. Hypoparathyroidism should be kept in the differential diagnosis of patients presenting with seizures and extrapyramidal features.

Life-threatening calcium channel blocker overdose and its management

A young woman presented to the emergency department with complaints of nausea, vomiting, pain in the abdomen and difficulty in breathing after ingestion of 56 tablets of amlodipine 5 mg each (total 280 mg of amlodipine). She was managed using hyperinsulinaemia/euglycaemia therapy and other measures like calcium gluconate, glucagon and vasopressors. She was discharged from hospital in a stable condition after 5 days.

Wunderlich's syndrome (spontaneous renal haemorrhage).

Wunderlichs syndrome is a rare condition characterised by spontaneous non-traumatic renal haemorrhage into the subcapsular and perirenal space. The commonest cause of Wunderlichs syndrome is renal neoplasms, with angiomyolipoma and renal cell carcinoma being the most common benign and malignant lesions, respectively. We report a case of Wunderlichs syndrome in a 46-year-old woman. She presented in the emergency department with the chief complaints of sudden onset of abdominal pain with no significant medical history. Imaging findings and clinical history led to the diagnosis of Wunderlichs syndrome. The patient underwent left partial nephrectomy and recovered without any complications. She is presently doing well.

Images in...: DRESS syndrome

DESCRIPTION A 16-year-old boy, a known case of epilepsy on oral phenytoin (300 mg/day) and folic acid (5 mg/day) for last 6 weeks, presented with complains of high-grade fever, jaundice and generalised erythematous eruption for 15 days duration. The eruption was maculopapular at onset, which desquamated in the next 3 days and changed to exfoliative dermatitis (figure 1). The patient was on no other medication. He had generalised tender lymphadenopathy, jaundice and tender hepatomegaly. Investigations revealed haemoglobin 12 g/dl, total leucocyte count 15 700/mm, differential leucocyte count revealed eosinophils 15%, polymorphs 52%, lymphocytes 28% and monocytes 5%. Serum bilirubin was 7.6 mg/dl (0.3–1.0 mg/dl), alanine aminotransferase and aspartate aminotransferase were more than five times the normal. Biopsy of a skin rash revealed spongiosis with intraepidermal vesiculation and patchy exocytosis with no specific pathology in the dermis. All other investigations including septicaemia profile and serology for viral hepatitis were negative. Diagnosis of drug rash with eosinophilia and systemic symptoms (DRESS) syndrome due to phenytoin was made. Phenytoin was discontinued, and patient was started on oral prednisolone at the dose of 1 mg/kg/day for 2 weeks, which tapered over a period of next 4 weeks. The patient showed rapid resolution of fever, eosinophilia and progressive improvement in skin rash and liver dysfunction over a period of 3 weeks. Our patient was diagnosed as DRESS syndrome as defined by Bocquet et al. Clinical features were typical: fever, rash followed by exfoliative dermatitis, lymphadenopathy, eosinophilia and hepatitis. Drugs that commonly cause DRESS syndrome include phenytoin, phenobarbital, carbamazepine, lamotrigine, minocycline, sulphonamides, sulphasalazine, trimethoprim, allopurinol, abacavir, nevirapine, mexiletine, isoniazid, gold salts, diltiazem, atenolol, captopril, azathioprine and dapsone. DRESS syndrome usually begins several weeks after exposure to the offending drug. The overall mortality in DRESS syndrome is about 10%. The most common differential diagnoses for DRESS syndrome are Stevens-Johnson syndrome/toxic epidermal necrolysis, hypereosinphillic syndrome and Kawasaki disease.

Painful Hip Leading to the Diagnosis of MEN 2B Syndrome

Context. MEN 2B syndrome is characterized by the presence of medullary thyroid cancer, pheochromocytoma, mucosal neuromas, marfanoid features, and skeletal abnormalities like kyphoscoliosis, joint laxity, pes cavus, and slipped capital femoral epiphysis (SCFE) in a minority; we present the case of a young female who was brought to medical attention due to painful hip because of SCFE. Case Report. A 16-year-old female presented to orthopedics out-patient department (OPD) with complaints of pain around the left hip and walking with a limp for the last two months. MRI of hip confirmed the presence of SCFE of the left hip. General examination detected thyroid swelling which was found to be a medullary thyroid cancer and imaging of abdomen confirmed the presence of bilateral pheochromocytoma, also present were neuromas of tongue and lips. Thus, a diagnosis of MEN 2B syndrome was made. Conclusion. SCFE can sometimes be the presenting feature of MEN 2B syndrome. Physicians should keep this in mind as it can lead to early diagnosis of a potentially lethal illness.

A case of primary cervicofacial hydatidosis

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Atypical giant haemangioma of liver with systemic inflammatory manifestations

Haemangioma is the most common benign tumour of the liver. Most of them are small in size (less than 4 cm) and are often asymptomatic and discovered incidentally on modern diagnostic imaging. Lesions with a diameter larger than 4 cm are called giant haemangiomas, and these are usually located in the right hepatic lobe. Although haemangioma is the most frequent benign tumour of the liver, ‘giant’ haemangiomas are rare. Such lesions may give rise to symptoms requiring treatment. In this case report, we describe the case of a 50-year-old Indian man who presented with giant liver haemangioma and systemic inflammatory manifestations.

Paradoxical reaction to antitubercular therapy in miliary tuberculosis

An 18-year-old boy presented with fever, weight loss and loss of appetite for 6 months duration. Investigation revealed raised erythrocyte sedimentation rate, negative sputum smear examination for acid-fast bacilli, x-ray and high-resolution CT chest showed bilateral, diffuse infiltration of lung parenchyma with miliary shadows. The patient was treated as a case of miliary tuberculosis with antitubercular therapy (ATT). On the 10th day of treatment the patient developed high-grade fever, cough and breathlessness. Chest x-ray showed an increased infiltration of lung parenchyma. The patient was diagnosed as a case of paradoxical reaction to ATT and was managed successfully with steroids.