Karthik N Rao

A Rare Case of Tamoxifen-Induced Thrombocytopenia

Breast cancer is a commonly encountered cancer in women. Tamoxifen is a frequently used drug in breast cancer. It is a selective estrogen receptor modulator (SERM). It is used for both chemoprevention and for palliative care in these patients. Drug-induced thrombocytopenia is a common diagnosis these days. Moreover, this condition can be life threatening or even fatal. It can either be due to increased platelet destruction or reduced formation. Either way, early diagnosis followed by discontinuation of the offending agent is the key to successful management. Here, we present a rare case of tamoxifen-induced thrombocytopenia.

Acute hepatitis E complicated by acute pancreatitis and multiorgan dysfunction

We report this rare case of a 27-year-old man who presented with acute hepatitis E and went on to develop acute epigastric pain. He was diagnosed to have acute severe pancreatitis with shock and acute renal failure due to hepatitis E. Such a phenomenon has rarely been reported in the literature, with patients following a benign course and complete recovery after conservative management and analgesia. Awareness of this potentially life-threatening complication, especially in young men from endemic areas with acute hepatitis E presenting with abdomen pain has been highlighted.

Lady Windermere Syndrome: A Very Rare Entity In Indian Medical Scenario

Bronchiectasis is a common respiratory disorder, which we come across in clinical practice. Patients with bronchiectasis are prone to infections, especially of Mycobacterium tuberculosis. However, non-tubercular Mycobacterial infections may also set in, though rare. Here, we report an unusual case of Mycobacterium avium complex infection in a case of middle lobe bronchiectasis that was seen in a middle-aged immunocompetent female, a syndrome known as Lady Windermere Syndrome.

An intriguing case of locked jaw secondary to melioidosis.

A 56-year-old woman presented with fever, pain and restriction of movement of the right temporomandibular joint. She was premorbidly diagnosed to have type 2 diabetes mellitus and rheumatoid arthritis. Local examination revealed a poorly demarcated severely tender, erythematous swelling in the right preauricular region. All haematological and biochemical investigations were within normal limits. MRI of the neck revealed the presence of a masticator space infection with intramuscular abscess involving the masseter and the temporalis muscles along with intracranial extension. Osteomyelitic changes were detected in the right mandibular condyle, temporal bone and in the temporomandibular joint. Melioidosis was suspected due to this unique clinical presentation of an abscess at an unusual and atypical site. Blood cultures identified the Gram-negative bacilli Burkholderia pseudomallei, which established the diagnosis of Melioidosis. Remarkable improvement was attained with antibiotics meropenem and cotrimoxazole, deferring the need for any surgical intervention.

Assessment of Cardiac Autonomic Function by Post Exercise Heart Rate Recovery in Diabetics

Abstract Background and Aims: Autonomic dysfunction in type 2 diabetes mellitus (DM) patients may translate into an increased cardiovascular morbidity and mortality. Autonomic system regulates ‘heart rate recovery’ (HRR), an important predictor of cardiovascular mortality, which can be assessed using the exercise electrocardiogram (ECG). Hence, utilizing HRR, this study assessed the autonomic function of the cardiovascular system after one minute of exercise stress test in both, patients with and without type 2 DM. Materials and Methods: A prospective case control study involving 50 patients with type 2 DM and 50 without type 2 DM, matched for age and sex, was carried out. Each subject underwent an exercise stress test by treadmill using the Bruce protocol. Cardiovascular parameters like heart rate was recorded using a 12 lead ECG along with blood pressure. Results: Patients with T2DM had lesser HRR after exercise (p < 0.001). Exercise capacity was significantly reduced among patients with T2DM when compared to controls (p = 0.01). A multiple linear regression analysis (R2=0.26) revealed that duration of diabetes (β=−0.02, p=0.048) and resting systolic blood pressure (SBP) (β=−010, p=0.048) are independent predictors of HRR. Conclusion: The study revealed HRR to be significantly reduced among patients with type 2 DM. HRR may hint at the presence of cardiac autonomic dysfunction and predict the cardiovascular mortality.

Utilization pattern of anti-diabetic drugs in type 2 diabetes mellitus in tertiary care hospital

Background: Diabetes mellitus is a major public-health related problem. The increase in prevalence rates has led to an increase in the economic burden, worldwide. To manage the disease in a better way, Drug utilization research can be used as a strategy to justify the drug therapy. Aims: To study the drug prescribing pattern of anti-diabetic drugs in newly diagnosed type 2 DM patients. Materials and methods: A retrospective observational study was carried out in a tertiary care hospital. As per the study criteria, data was collected from medical records department (MRD) registry using ICD code E 11.9.Data was analysed using SPSS 20.0 and the DDD per 100 bed-days was calculated. Results: A total of 662 patients were newly diagnosed with type 2 DM. The mean age of study population was 52.5 ± 12.5 years and 427(64.5%) patients were male. Hypertension was the most common comorbidity observed in 189 (28.5%) patients. Among the anti-diabetic drugs, the utilization of insulin (0.088 DDDs per 100 bed-days in 2013 and 0.16 DDDs per 100 bed-days in 2014) was highest and among the oral anti-diabetic drugs the utilization pattern of metformin (0.058 DDDs per 100 bed-days in 2013 and 0.071 DDDs per 100 bed-days in 2014) was the highest in both 2013 and 2014. Conclusion: Biguanides (metformin) was highly prescribed anti-diabetic drug in both single and combination drug therapies. This study shows that the treatment pattern of type 2 DM patients is in accordance to the NICE (National Institute for Health and Clinical Excellence) guidelines.

Addison’s Disease Mimicking as Acute Pancreatitis: A Case Report

Over past two decades there has been significant improvement in medical field in elucidating the underlying pathophysiology and genetics of Addisons disease. Adrenal insufficiency (Addisons disease) is a rare disease with an incidence of 0.8/100,000 cases. The diagnosis may be delayed if the clinical presentation mimics a gastrointestinal disorder or psychiatric illness. We report a case of Addisons disease presenting as acute pain in abdomen mimicking clinical presentation of acute pancreatitis.

Echocardiographic abnormalities in cirrhosis & their correlation with severity of cirrhosis using Child-Pugh score among patients in a tertiary care hospital

Background & objectives: Child-Pugh score (CPS) is a widely used prognostic marker in cases of cirrhosis and pulmonary arterial hypertension (PAH). However, the role of this score in the quantification of severity of PAH is not well studied. In mild cases, echocardiography is more sensitive. This study was done to assess the association between echocardiography and severity of cirrhosis using CPS. Methods: A cross-sectional study was done from April to June 2014 in 42 patients with cirrhosis using a pre-tested semi-structured interview schedule. Results: There was no significant association between echocardiographic changes and CPS in patients with liver cirrhosis. Interpretation & conclusions: Advising an echocardiographic evaluation may prove beneficial in patients of Child-Pugh Grades B and C. However, more extensive studies are required to confirm the same.

Central retinal artery occlusion as a presenting manifestation of polycythaemia vera

A 60-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the left eye (LE). Best-corrected visual acuity in the LE was counting fingers close to face. A relative afferent pupillary defect was observed in the LE. Ocular fundus examination of LE was suggestive of central retinal artery occlusion. Systemic evaluation revealed splenomegaly and normal cardiac and carotid arteries. Haematological investigations revealed increased haemoglobin, haematocrit, platelet count and leucocytosis with low erythrocyte sedimentation rate (ESR). Features of myeloproliferative neoplasm were noted on bone marrow aspiration. An assay for JAK2 mutation was positive. Since erythropoietin levels were normal, a diagnosis of primary polycythaemia vera was made and treated with aspirin and phlebotomy twice weekly until the target haematocrit of under 45% was achieved.