Joe Devasahayam

A rare case of pericarditis, complication of infliximab treatment for Crohn's disease.

Dear Sir, Infliximab, a monoclonal anti-TNFα antibody, is a widely used drug in the treatment of inflammatory bowel disease. Various adverse reactions including infusion reactions, reactivation of tuberculosis, serum sickness, hematologic or bronchogenic malignancies are attributed to infliximab therapy. Pericarditis as one of the adverse reactions is very rarely reported. We present a case of pericarditis that occurred in a patient with refractory ulcerative colitis soon after initiating infliximab therapy. A 59 year old Vietnamese male presented with a 2-week history of hematochezia associated with intermittent episodes of abdominal pain relieved by defecation. He was having about 8–10 bowel motions per day which was interfering with his daily activities. His did not have any significant past medical problems, but for 30 pack years history of smoking. On examination, he was afebrile and with normal vital signs. His physical examination showed mild generalized abdominal tenderness on deep palpation. Examination of other systems was negative for any other abnormality. His initial abdominal CT scan showed bowel thickening …

Long-acting Muscarinic Antagonist Versus Inhaled Corticosteroid when Added to Long-acting β-agonist for COPD: A Meta-analysis

ABSTRACT The purpose of this study was to systematically review the efficacy and safety of long-acting β-agonist/long-acting muscarinic antagonist (LABA/LAMA) and LABA/inhaled corticosteroid (ICS) combinations in patients with advanced chronic obstructive pulmonary disease (COPD). Randomized clinical trials of at least 12 weeks of duration comparing LABA/LAMA and LABA/ICS combinations were included. We chose forced expiratory volume in 1 second (FEV1), St. Georges Respiratory Questionnaire (SGRQ) score, Transitional Dyspnea Index (TDI), COPD Assessment Test (CAT) score, COPD exacerbations, mortality, and other safety parameters as outcome assessment criteria. We included six randomized controlled trials with a total of 4,319 patients. Most patients did not have a history of exacerbation. LABA/LAMA was associated with greater improvement in FEV1 than LABA/ICS (mean difference (MD) 0.09L, 95%confidence interval (CI) 0.07 to 0.11L; high certainty). Two treatments appeared clinically equivalent in improving SGRQ (MD −0.12, 95%CI −1.16 to 0.92; high certainty), TDI (MD 0.15, 95%CI −0.05 to 0.35; high certainty), and CAT scores (MD 0.28 95%CI −0.29 to 0.85; moderate certainty). LABA/LAMA was associated with an absolute reduction of approximately 8% in the incidence of pneumonia compared with LABA/ICS (risk ratio 0.41, 95%CI 0.18 to 0.94; moderate certainty). There was no significant difference in safety and exacerbation outcomes. However, equivalence of two treatments could not be concluded due to imprecision especially for mortality, cardiac serious adverse events, and severe exacerbations. Our findings support the use of dual long-acting bronchodilators for patients with advanced COPD but without frequent exacerbations given the excess risk of pneumonia with LABA/ICS.

Invasive Saccharomyces cerevisiae infection: A friend turning foe?

We report a very rare case of acute pyelonephritis in a 51-year-old female with a history of chronic kidney disease (CKD) and diabetes caused by a normally benign and a well-known human commensal organism, Saccharomyces cerevisiae that is very often prescribed as a probiotic in modern medical practice. The causal role of S. cerevisiae was confirmed by its isolation in blood, urine, stool as well as vaginal swabs thus proving its virulent nature in suitable situations.

C1q Nephropathy: The Unique Underrecognized Pathological Entity.

C1q nephropathy is a rare glomerular disease with characteristic mesangial C1q deposition noted on immunofluorescence microscopy. It is histologically defined and poorly understood. Light microscopic features are heterogeneous and comprise minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), and proliferative glomerulonephritis. Clinical presentation is also diverse, and ranges from asymptomatic hematuria or proteinuria to frank nephritic or nephrotic syndrome in both children and adults. Hypertension and renal insufficiency at the time of diagnosis are common findings. Optimal treatment is not clear and is usually guided by the underlying light microscopic lesion. Corticosteroids are the mainstay of treatment, with immunosuppressive agents reserved for steroid resistant cases. The presence of nephrotic syndrome and FSGS appear to predict adverse outcomes as opposed to favorable outcomes in those with MCD. Further research is needed to establish C1q nephropathy as a universally recognized distinct clinical entity. In this paper, we discuss the current understanding of pathogenesis, histopathology, clinical features, therapeutic options, and outcomes of C1q nephropathy.

Group A Streptococci-Associated Necrotizing Fasciitis following Cat Bite in an Immunocompromised Patient

Necrotizing soft tissue infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. Mortality rate is very high and could be even higher in an immunocompromised host. We present a 57-year-old female with history of rheumatoid arthritis on oral corticosteroid and methotrexate therapy with painful swelling of the left hand following a cat bite that was diagnosed as having group A streptococcus pyogenes-associated necrotizing fasciitis. Treatment with ampicillin-sulbactam, Clindamycin, and surgical debridement was performed. In spite of all the adequate therapy she succumbed to death from streptococcal toxic shock and related complications after thirty-two days of treatment in intensive care unit. Necrotizing fasciitis is an uncommon but life-threatening complication in immunocompromised hosts. Tissue infections in cat bite wounds are commonly caused by pathogenic bacterium known as Pasteurella multocida. Group A streptococcal infections are not reported following cat bites. A high index of suspicion must be maintained to suspect group A streptococcal associated necrotizing fasciitis following cat bites and an early medical and surgical intervention should be made for any best possible outcome.

Sleep Issues in Myopathic Disorders and Muscular Dystrophies

Myopathies and muscular dystrophies are disease inherent to muscles and have the common feature of muscle weakness. Multiple sleep disorders are associated with them. Sleep disordered breathing disorder (SRBD) is the most common sleep disorder in both myopathies and muscular dystrophies. Various different factors contributed to the development of SRBD that include diaphragmatic involvement, coexisting cardiac abnormalities, reduction in lung volumes and capacities, and airway obstruction. Other sleep disorders in these conditions include insomnia, restless legs syndrome, hypersomnolence, and parasomnias.

Basics and Practical Aspects of Non-invasive Mechanical Ventilation

Artificial ventilation is a lifesaving measure in the setting of respiratory failure. However, invasive ventilation using endotracheal tube or tracheostomy tube is ridden with risks and side effects. Non-invasive ventilation (NIV) has proven to be a valuable tool in some patients that don’t require invasive methods. From the primitive negative pressure “Iron Lung” ventilators to the most sophisticated automated positive pressure delivery ventilators, NIV has come a long way to become an important part of the care of the patients in respiratory failure. In this chapter, we aim to discuss the basic principles involved in NIV and the various NIV options available to the patients.

Colonic Mucosal Ulceration and Gastrointestinal Bleeding Associated with Sevelamer Crystal Deposition in a Patient with End Stage Renal Disease

End stage renal disease (ESRD) population account for 1.9 per patient year of hospital admissions annually. ESRD population are at increased risk of bleeding secondary to use of anticoagulation during hemodialysis and uremia induced platelet dysfunction. Gastrointestinal bleeding accounts for 3–7% of all deaths in ESRD population. Lower gastrointestinal bleeding refers to blood loss from a site in the gastrointestinal tract distal to the ligament of Treitz. It is usually suspected when a patient complains of hematochezia. It is different from patients presenting with hematemesis that suggests bleeding from upper gastrointestinal tract. Common causes of lower gastrointestinal bleed include diverticulosis, ischemia, hemorrhoids, neoplasia, angiodysplasia, and inflammatory bowel disease. ESRD patients are known to retain phosphate alone or in combination with calcium which has been associated with high mortality. Sevelamer is a phosphate binder used widely in ESRD population. The known side effects of sevelamer include metabolic acidosis, vomiting, nausea, diarrhea, dyspepsia, abdominal pain, constipation, flatulence, fecal impaction, and skin rash. We are reporting a unique case of a 56-year-old female with end stage renal disease on sevelamer hydrochloride who presented with gastrointestinal bleeding and underwent a right hemicolectomy found to have sevelamer-induced mucosal ulceration and crystal deposition in the colonic mucosa. This case report highlights the fact that, with widespread use of this medication in the patients with chronic kidney diseases, physicians should be aware of this underrecognized entity in the differential diagnosis of gastrointestinal bleed in ESRD patients.

An under recognized cause of chest pain.

Aortic intramural hematoma (IMH) is related to but is pathologically distinct from aortic dissection. In this potentially lethal entity, there is hemorrhage into the aortic media in the absence of an intimal tear. With recent advances in imaging techniques, IMH is now increasingly recognized. The limited data available suggest that the clinical course of IMH mimics that of acute aortic dissection, and mortality rates are similar. Physicians need to be cognizant regarding this entity when they are evaluating chest pain. Here we report a case of IMH, in a 63-year-old female, which was managed conservatively.