John Mathew

Eosinophilic esophagitis and pharyngitis presenting as mass lesion in a patient with inactive rheumatoid arthritis.

We describe here a case of longstanding rheumatoid arthritis (RA) presenting with recurrent episodes of epigastric pain, melena, nonprogressive dysphagia, and hoarseness associated with persistent peripheral blood eosinophilia. Her RA was clinically inactive, but she had significant lymphadenopathy and hepatosplenomegaly. Computed tomographic scan of the thorax revealed circumferential wall thickening extending from the oropharynx to the gastroesophageal junction with a large polypoidal mass projecting into the lumen of the stomach. Histology revealed infiltration of the esophageal mucosa by eosinophils with a density of 40 to 80 per high-power field. The stratified squamous epithelium of the pharyngeal mucosa was also infiltrated by eosinophils with a density of more than 100 per high-power field. Eosinophilic esophagitis and pharyngitis were diagnosed, and the patient was administered corticosteroids and hydroxyurea, following which her symptoms resolved. On repeat imaging, there was significant reduction in esophageal wall thickening and luminal dilatation. There are few reports of tissue eosinophilia in association with RA, but the pathogenesis and any definite association with RA are not clear.

X-rays in the evaluation of adenoid hypertrophy: It's role in the endoscopic ERA

ObjectivesTo evaluate the reliability of X-rays in the diagnosis of adenoid hypertrophy and to validate this with flexible nasopharyngoscopy which is the existing gold standard.MethodLateral radiograph of the neck and a flexible nasopharyngeal endoscopy was done to evaluate adenoid enlargement in children aged 3–12 years who were included in a S week randomized double-blind placebo controlled study for the effect of beclomethasone in adenoid hypertrophy. These were graded independently by both the co-investigor and investigator X-ray and nasal endoscopy for reevaluation of adenoid size was done at the completion of the study. Variables of both the procedures were scored at the beginning and end of the study. The agreement between the two groups was assessed using weighted kappa statistic.ResultsThere were 26 patients in the study, 17 of them had complete correlation between the X-ray and endoscopy findings. The agreement between these findings was statistically significant (p<01) with the weighted kappa 0.51.ConclusionThis study shows that lateral X-rays of the neck, besides being a noninvasive procedure, still remains a very reliable and valid diagnostic test in the evaluation of hypertrophied adenoids.

Detection of odoriferous subgingival and tongue microbiota in diabetic and nondiabetic patients with oral malodor using polymerase chain reaction

BACKGROUND Halitosis has been correlated with the concentration of volatile sulfur compounds (VSCs) produced in the oral cavity by metabolic activity of bacteria colonizing the periodontal pockets and the dorsum of the tongue. It has been assumed that there is a relationship between periodontal disease and diabetes mellitus. OBJECTIVES The aim of the study was to assess the malodor using the organoleptic method and tanita device; to quantify odoriferous microorganisms of subgingival plaque and tongue coating, such as P. gingivalis (Pg), T. forsythia (Tf), and F. nucleatum (Fn) using polymerase chain reaction (PCR) in nondiabetic and diabetic chronic periodontitis patients. PATIENTS AND METHODS Thirty chronic periodontitis patients (with and without diabetes) with 5-7 mm pocket depth, radiographic evidence of bone loss, and presence of oral malodor participated in this study. Subjective assessment of mouth air was done organoleptically and by using a portable sulfide monitor. Tongue coating was also assessed. RESULTS The scores of plaque index, gingival index, gingival bleeding index, VSC levels, and tongue coating between the nondiabetic and diabetic patients were not significant (P>0.5). In nondiabetic patients, Fn was found to be significantly (P<0.5) more in tongue samples, whereas Pg and Tf have not shown significant values (P>0.5). In diabetic patients, Fn and Tf have shown significant (P<0.5) an increase in subgingival and tongue samples, respectively, whereas Pg has not shown significant difference between subgingival and tongue samples. INTERPRETATION AND CONCLUSION The results confirm that there is no difference in clinical parameters between nondiabetic and diabetic periodontitis patients, but the odoriferous microbial profiles in tongue samples of diabetic patients were found to be high. However, there is a weak positive correlation between VSC levels, clinical parameters, and odoriferous microbial profiles.

Congenital nasal pyriform aperture stenosis: A rare cause of nasal airway obstruction in a neonate

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal airway obstruction that clinically mimics choanal atresia, but needs to be differentiated from the latter because of the widely divergent modes of management. We present a case of CNPAS, to highlight the importance of recognizing the classic signs of CNPAS on cross-sectional imaging.

Septate fungal invasion in masked mastoiditis: a diagnostic dilemma

Invasive fungal mastoiditis is a rare entity, seen almost entirely in immunocompromized patients. It has been reported primarily in patients with leukaemia and more recently with acquired immunodeficiency syndrome. A literature search revealed only a few reports in diabetic patients, in whom the invasive fungus was identified as mucormycosis in all cases. We report the first case in the English literature of invasive septate fungal mastoiditis in a diabetic patient with intact tympanic membranes.

Wegener's granulomatosis : a rare presentation

Wegener’s granulomatosis (WG) is a necrotizing granulomatous vasculitis involving the nose, paranasal sinuses, lungs, and kidneys. There are two types of WG—systemic, which is characterized by focal segmental necrotizing glomerulonephritis and limited in which the kidneys are spared. Without proper immunosuppression, WG can be aggressive and often fatal. There are very few reports on WG presenting as parotitis and lacrimal gland involvement. We report a lady who presented recurrent parotitis, focal segmental glomerulosclerosis, and orbital cellulitis, in whom the final diagnosis was revealed after an open lung biopsy.

Pancreatitis in Systemic Lupus Erythematosus - Case Series from a Tertiary Care Center in South India

Pancreatitis in Systemic Lupus Erythematosus (SLE) is a rare, but life threatening complication. We aimed to study the characteristics and treatment outcome of SLE patients with acute pancreatitis in comparison with those with abdominal pain due to causes other than pancreatitis. Records of SLE patients admitted in our ward with pain abdomen between January 2008 and July 2010 were studied retrospectively. Of 551 SLE in-patients during the study period, 28 (5%) had abdominal pain and 11 (2%) of them were diagnosed to have acute pancreatitis. Five of the 11 patients had severe pancreatitis and 6 had mild pancreatitis. Seizures, arthritis and lack of prior use of steroids were significantly more common in patients with pancreatitis as compared to those with abdominal pain of non pancreatic origin. Seizure occurred more often in severe pancreatitis group as compared to mild pancreatitis. There was no difference in prevalence of lupus anticoagulant and anticardiolipin antibody (40%) between SLE patients with pancreatitis and those with other causes of abdominal pain. Conclusion: Association of pancreatitis in our cohort of SLE patients include withdrawal of maintenance dose of steroids, seizures and arthritis in univariate analysis. However there was no independent predictor of this complication in our study.

Endoscopic Repair of CSF Fistulae: A Ten Year Experience

INTRODUCTION Cerebrospinal Fluid (CFF) fistulae are repaired endoscopically with varying degrees of success around the world. Large series are still uncommon, and the results varied primarily because of the different techniques by different surgeons and also because of a variation in the patient profile in each series, for example, many series deal primarily with traumatic CSF leaks where the defects are larger and outcomes poorer. AIM To analyse the surgical outcomes of Endoscopic CSF rhinorrhea closure. MATERIALS AND METHODS This is a series of 34 cases operated upon primarily by one surgeon in two different centres over a period of 10 years. RESULTS Of the 34 cases, 76% of the patients were women. Among the patients only 20.6% patients had a history of trauma preceding the CSF leak. The most common site of leak was in the fovea ethmoidalis in 19 (55.8%) followed by 10 (29.4%) in the cribriform plate. An overlay technique of placing the multiple layers of fascia and mucosa was used in 26 (76.5%) patients and underlay technique in the remaining. Postoperative lumbar drain was used in all patients. CONCLUSION Based on the treatment outcome of the 34 patients, it can be concluded that the success rate of a single endoscopic procedure in our experience is 97% and 100% following the second. Endoscopic approach for closure of CSF leak is safe with minimal complications and little morbidity.

A Randomized Controlled Trial Comparing Intranasal Midazolam and Chloral Hydrate for Procedural Sedation in Children.

Objectives To evaluate the efficacy and safety of intranasal midazolam and chloral hydrate syrup for procedural sedation in children. Study Design Prospective randomized placebo-controlled trial (double blind, double dummy). Setting Tertiary care hospital over 18 months. Subjects and Methods Eighty-two children, 1 to 6 years old, undergoing auditory brainstem response testing were randomized to receive either intranasal midazolam with oral placebo or chloral hydrate syrup with placebo nasal spray. Intranasal midazolam was delivered at 0.5 mg/kg (100 mcg per spray) and oral syrup at 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologist’s satisfaction, time to recovery, and number of attempts. Results Forty-one children were in each group, and no major adverse events were noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with the intranasal midazolam group (33%). Significant difference in time to recovery was noted in the chloral hydrate group (78 minutes) versus the intranasal midazolam group (108 minutes). The parents’ and audiologist’s satisfaction was higher for chloral hydrate (95% and 75%) than for intranasal midazolam (49% and 29%, respectively). Overall, sedation was 95% with chloral hydrate versus 51% with intranasal midazolam. Both drugs maintained sedation. Conclusions Intranasal midazolam and chloral hydrate are both safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam, with an earlier time to onset of sedation, a faster recovery, better satisfaction among parents and the audiologist, and successful sedation.

Serum Cytokine Profile in Asian Indian Patients with Takayasu Arteritis and its Association with Disease Activity

Background: Arterial inflammation Takayasu arteritis (TA) is an outcome of balance between pro- and anti-inflammatory cytokines. Comprehensive assessment of these cytokines is important for understanding pathogenesis and assessing disease activity. Objective: To study pro- and anti-inflammatory cytokines representing different T-helper cell pathway in serum samples of Asian Indian patients with TA and to assess their association with disease activity. Methods: Consecutive Indian patients with TA were assayed for serum interferon-γ, interleukin-6, interleukin-23, interleukin-17, interleukin-10 and transforming growth factor- β levels at baseline and follow up visit. Patients were grouped into active and stable disease based on Indian Takyasu Arteritis clinical Activity Score-2010. Serum levels of these cytokines between active and stable disease and between baseline and follow up visits were compared by non-parametric tests. Results: Among 32 patients enrolled, 15 were classified as active while 17 as stable disease at baseline. IFN-γ levels were significantly higher in active disease than stable disease (p=0.0129) while other cytokines did not differ significantly between 2 groups. Serum levels of none of the cytokines changed significantly over 2 visits in both responders and non-responders. IL23 levels positively correlate with disease duration ((r=0.999; p<0.005). Modest correlation was observed between IFN-γ and IL23 levels at both baseline and follow up and between IFN-γ and IL-6 and CRP at follow up. Conclusion: IFN-γ levels are raised in active disease in TA and correlates well with other biomarkers of disease activity and proinflammatory cytokines. There is also a direct correlation between Il-23 levels and disease duration.