Jyoti Jain

Orbital tuberculosis manifesting as proptosis in an immunocompromised host.

UNLABELLED Orbital tuberculosis is an extremely rare, potentially devastating state, when not effectively treated, can lead to grave sequelae. Proptosis can be the result of primary orbital pathology or systemic disease processes. (1, 2) Thyroid ophthalmopathy being commonest cause of proptosis .It can also be a manifestation of, diseases involving various structures of orbit and of superior orbital fissure or cavernous sinus. A case of orbital tubercular abscess presenting with proptosis and blindness in a young male 27 years is reported. Clinicians should suspect rare causes in an immuno- compromised host .(2, 3) The failure to diagnose these conditions can lead to unintended sequelae. KEY MESSAGE The patient who presents with proptosis must be evaluated to ascertain the causation. Preservation of vision is of paramount importance. On follow-up patients should be monitored for complications and remedied.

Stroke intracerebral multiple infarcts: Rare neurological presentation of honey bee bite

Honey-bee bites which require urgent hospitalization is very rare. It is mainly seen as occupational hazards in farmers, tree dwellers and honey collectors. Common clinical presentation includes minor localized reactions in form of swelling and redness sometimes anaphylactic reaction. Infrequent major complications reported from different studies include rhabdomyolysis, acute renal failure (ARF), acute pulmonary edema, intravascular coagulation, encephalopathy and very rarely cerebral haemorrhage. Stroke due to multiple intra- cerebral infarcts along with rhabdomyolysis in patient of honey-bee bite is rare neurological complication. We report a case of 70 year man with honey-bee bite and multiple intracerebral infarcts presented as stroke, and rhabdomyolysis and ARF. When a patient presented with honey-bee bite, one should suspect serious complications. Despite advances in the understanding of pathophysiology its complications remains enigmatic and in some instances may be multifactorial. Various therapeutic interventions if started early after diagnosis reduces the possible consequences as potential reversibility of the illness.

Prevalence and Correlates of Metabolic Syndrome in Young Population: A Cross Sectional Study

Background: The Metabolic Syndrome (MS) is emerging as one of the major public health problem all over the world including India. It confers increased risk of Cardiovascular Disease (CVD) and Diabetes Mellitus (DM), both of which pose a huge burden over the society and economics. This study was conducted to assess the prevalence and correlates of MS in young population. Settings and design: A cross-sectional study was performed in Department of Medicine of a rural teaching tertiary care hospital in central India. Materials and methods: In all consecutive study subjects, a National Cholesterol Education Programme Adult Treatment Panel (NCEP ATP – III) criteria was applied to assess the magnitude of MS. Statistical analysis: Prevalence of MS was expressed in percentage. For determining the association of risk factors with MS, we used Student’s t-test to test for continuous variables Chi square for categorical variables and Fisher exact test in the case of small cell sizes (expected value<5). Association was considered statistical significant when P value was ≤ 0.05. Results: The magnitude of MS was 11.2%. Conclusion: Metabolic syndrome exists in significant number of young student population. The early identification of MS and associated risk factors can help to prevent or delay MS, diabetes and CVD by modifying their lifestyle.

Magnitude of peripheral neuropathy in cirrhosis of liver patients from central rural India

Context: Cirrhosis of liver is an important cause of morbidity and mortality and if associated with peripheral neuropathy (PN) it also poses a huge financial, psychological burden for the patients and their families. Aim: The aim of the present study was to study the magnitude of PN among subjects with cirrhosis of liver presenting to tertiary care teaching hospital in central rural India. Settings and Design: A cross-sectional study was performed in a tertiary care teaching hospital. Materials and Methods: In all patients of cirrhosis of liver irrespective of etiology, aged 15 and above, undergone clinical assessment for peripheral nervous systems damage and confirmed by nerve conduction studies. Statistical Analysis Used: We used chi square test to study associations. P value ≤0.05 was considered as significant. Crude odds ratios were computed to assess the strength of association between independent variables and dependent variables along with their 95% confidence intervals. Results: We included 207 of cirrhosis of liver patients admitted in medicine department from November 2010 through November 2013. Nearly 83% patients were male and 63.2% patients were under the age of 45 years. Common features in these patients were ascites (71%) splenomegaly (63.3%) pedal edema (61.4%) icterus (46.4%) tingling (44.9%) gastrointestinal bleeding(39.1%), ataxia (26.6%), numbness(26.6%), distal motor weakness (21.7%) and paresthesia(20.8%). Among the manifestation of peripheral nerve involvement, loss of ankle reflex was the most common feature in 51.7%, followed by loss of temperature sense 29.5%, loss of vibration sense 20.8%, loss of touch 16.4%, loss of position sense 14.5% and loss of pain in 6.3% of the patients. Peripheral neuropathy was found in 53.6% [95% CI: 46.58- 60.56] study subjects on electrophysiological study. Conclusions: Analysis of electrophysiological study shows that the PN is very common in study subjects with cirrhosis of liver, especially in male subjects, during the middle age group.

A rare case of situs inversus with dextrocardia, lutembacher syndrome, and pericardial effusion.

Incidence of congenital cardiac anomalies in dextrocardia with situs inversus is low as compared to congenital cardiac anomalies in isolated dextrocardia. We describe the first ever case of situs inversus with dextrocardia, Lutembachers syndrome, and pericardial effusion. The pericardial effusion in our case was acquired and was tubercular in etiology.

Polyglandular autoimmune syndrome: We should entertain this possibility more than often

Polyglandular autoimmune syndrome (PGS) type III is a rare immune-mediated disorder. Common clinical presentation includes symptoms of hypothyroidism, diabetes, pernicious anemia, vitiligo, and autoimmune alopecia. Other autoimmune disorders associated with PGA syndrome III are celiac disease, hypogonadism, myasthenia gravis, sarcoidosis, rheumatoid arthritis, inflammatory bowel disease, gastric carcinoid tumor, and hepatitis C. We report a case of PGA syndrome type III in an 18-year-old male. Hashimotos thyroiditis was diagnosed when he was 13 years old. Clinical examination and laboratory findings revealed a PGS due to the presence of immune-mediated diabetes mellitus (DM) (type 1 DM), insufficient insulin hormone response, and thyroid autoimmunity. The patient had neither adrenal disease nor hyperparathyroidism. Therefore, we concluded that this patient has PGS type III A. When a patient presented with PGS, we should continue to consider other glandular hypofunction when evaluating patients with any type of endocrine hypofunction, as the risk of multiple glandular involvements is quite significant. Various therapeutic interventions if started early after diagnosis reduces the possible complications of the illness.

Carotid intima-media thickness and apolipoproteins in patients of ischemic stroke in a rural hospital setting­ in central India: A cross-sectional study

Context: Carotid intima-media thickness (CIMT) and apolipoproteins have been found as a risk factor for ischemic stroke Objective: The objective was to study the carotid intima-media thickness, apolipoproteins, and their relation in patients of ischemic stroke in central rural India. Settings and Design: A cross-sectional study was performed in a rural hospital in central India. Materials and Methods: In all patients of ischemic stroke proven by computerized tomography (CT), CIMT, apolipoprotein A-I (ApoA-I), and apolipoprotein B(ApoB) were measured. Statistical Analysis Used: We used Students t-test to compare means, a chi-square test to compare proportions, and a Mann-Whitney test to compare medians. A P value <0.05 was considered significant. Results: The mean age of our study population (N=106) was 61 years. The mean CIMT was 0.83 mm ranging from a minimum of 0.45 mm to a maximum of 1.096 mm. Mean CIMT was significantly higher than expected 0.67 values, which was calculated according to the age of the study population. The association of decreased ApoA-I < 100 mg/dl and increased ApoB > 90 mg/dl with CIMT > 0.7 mm was statistically significant with P<0.001. Conclusions: The CIMT in computerized tomography-proven ischemic stroke was significantly higher than expected for the age of the study population. The relation of decreased ApoA-I and increased ApoB with CIMT > 0.7 mm was also statistically significant.

Prevalence of skin diseases in rural Central India: A community-based, cross-sectional, observational study

Aim: To identify prevalence of skin diseases and to determine the risk factors of skin diseases among the adult population of rural Central India. Materials and Methods: It was a community-based, observational study in which we prospectively recruited general population in and around Wardha beginning October 1, 2011, through March 2012. The main focus was to study population of 10 years and above. Results: Eczema was the most common dermatosis accounting for 22% participants and among them almost 60% sufferers were female. Fungal infection presented in 13.0% of all the affected participants and was found more in male participants (58%) than in female (42%) among those affected with fungal infection. Eczema, benign skin tumors, and pigmentary disorders were more common in participants aged 51 years and above accounting to 52.7%, 9.4%, and 6.3%, respectively. Fungal infection and acne were more in adolescent age group accounting to 17.4% and 30.4%, respectively. Conclusion: Hence, we concluded that of the entire study population prevalence of skin diseases was 60%. Our study brought a higher prevalence of eczema in female and fungal infection in male. Eczema, benign skin tumors, and pigmentary disorders were more common in participants aged 51 years and above, and fungal infection and acne were more in adolescent age group. Adolescents suffered predominantly from fungal infections and acne due to pubertal changes. Various causes such as environment, overcrowding, and poor living conditions are major factors and not only adolescents or old age group but also entire population between 21 and 50 years of age were found to be suffering more commonly from eczema and infective dermatoses.

Magnitude and pattern of autonomic neuropathy in cirrhosis of liver: A cross-sectional study from central rural India

Background: Cirrhosis of liver is an important cause of morbidity and mortality. Autonomic neuropathy need to be focused as it is independent predictor of mortality with 5-fold increased risk in patients with chronic liver disease (CLD). The aim of the present study was to study the magnitude and pattern of autonomic neuropathy (AN) among subjects with cirrhosis of liver presenting to teaching hospital in central rural India. Methodology: A cross-sectional study was performed in a tertiary care teaching hospital. In all patients of cirrhosis of liver irrespective of etiology, aged 15 and above, underwent clinical assessment and cardiovascular autonomic function tests to confirm autonomic nervous systems damage. We used chi square test to study associations. P value ≤0.05 was considered as significant. Crude odds ratios were computed to assess the strength of association between independent variables and dependent variables along with their 95% confidence intervals. Results: We included 199 cirrhosis of liver patients admitted in medicine department from November 2010 through November 2013. Nearly 83% patients were male and 63.3% patients were under the age of 45 years. Common features present in these patients were ascites (67.8%), splenomegaly (63.5%), pedal edema (60.3%), icterus (45.2%) and gastrointestinal bleeding (39.7%). Among the manifestation of autonomic nerves involvement dizziness on standing was the most common feature in 47.2%, followed by gustatory sweating in 21.6%, and nocturnal diarrhoea in 21.1%. Autonomic neuropathy was found in 70.9% [95% CI: 64.02-77.17] of study subjects on cardiovascular autonomic function tests. Conclusions: Analysis of cardiovascular autonomic function tests shows that the AN is very common in subjects with cirrhosis of liver.

Combined bilateral retinal arteriolar and retinal vein occlusion: An unusual presentation of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a rare autoimmune disease associated with multi-organ damage mediated by tissue-binding autoantibodies and immune complexes. [1] Common ocular manifestations of SLE include nonspecific conjunctivitis, anterior uveitis, or iridocyclitis, which rarely threaten vision. In contrast, retinal vasculitis and optic neuritis are serious manifestations. [2] Branch retinal arteriolar occlusion (BRAO) and branch retinal vein occlusion (BRVO) in patients younger than 30 years of age is rarely caused by atheromatous diseases. Other diverse etiologies are more likely to be inflammatory and infectious conditions. Here, we have report a case of a 17-year-old woman with SLE and hypocomplementenemia, who presented with sudden loss of vision. A rare presentation of SLE is found as combined BRAO and BRVO in both the eyes (OU). Despite advances in the understanding of pathophysiology of SLE, its complications remains enigmatic and, in some instances, it may be multifactorial. Early accurate diagnosis and aggressive immunosuppression is recommended, which helps in the management and preservation of the vision.