Kashif Aziz

DIARRHŒAL MORTALITY IN TWO BANGLADESHI VILLAGES WITH AND WITHOUT COMMUNITY-BASED ORAL REHYDRATION THERAPY

To combat dehydration from diarrhoea in Shamlapur, a village of 7021 people, multiple community-based points were set up by trained volunteers for the distribution of glucose-electrolyte oral rehydration salt (ORS) packets. The comparable adjoining village, Bordil, with a population of 3888, obtained its supply of ORS from Shamlapur. Surveilance for 2 years showed that although diarrhoeal attack-rates were equal, consumption of ORS after diarrhoea was 80% in Shamlapur and 38% in Bordil. There were 8 deaths in Shamlapur caused by diarrhoea and 23 in Bordil, showing an overall case fatality-rate of 0.5% and 2.4%, respectively, and a diarrhoeal mortality-rate per 1000 population of 0.6 and 2.9, respectively. The observation indicated that although it may not be possible to reduce diarrhoeal attack-rates, easy availability of rehydration solution and its early use after village-based training may save many lives, particularly those of children.

Do repeated attacks of acute diarrhoea cause chronic diarrhoea

Publisher Summary This chapter discusses the role of repeated attacks of acute diarrhea that cause chronic diarrhea. In a study reviewed in the chapter, the number of attacks experienced by the children during the preceding one year according to the duration of the longest episode is shown. It may be seen that children who experienced repeated attacks gave a history of longer lasting diarrheal episodes as compared with the children experiencing fewer attacks. It is found that the fact that a higher proportion of children having shigellosis during the preceding one year tended to give a history of diarrhea of longer duration. The chapter reviews the percentage distribution of diarrheal episodes by duration and the number of attacks during the preceding one year. It also confirms findings that the highest proportion of children giving a history of repeated diarrheal episodes shows diarrhea of longer duration. Statistically, the differences were highly significant. This preliminary analysis of prior diarrheal experience and the duration of subsequent attack clearly establish the fact that children having repeated episodes tend to have diarrhea of longer duration. It is found that without further investigation of the etiological agents responsible for these diarrheas, it is difficult to speculate on their pathogenesis.

A Patient with Artifactually Low Serum High Density Lipoprotein Cholesterol Due to Waldenstrom Macroglobulinemia

When very low or undetectable high density lipoprotein (HDL)-cholesterol (HDL-C) is encountered in clinical practice, a paraproteinemia should be suspected in the absence of genetic or more obvious secondary causes. We reported a case of artifactually low HDL-C in a 68-year-old man with a past medical history of vitamin B12 deficiency. Lipid panel showed total cholesterol (TC) 144 mg/dl, triglycerides (TG) 79 mg/dl, HDL-C 5 mg/dl, and low density lipoprotein (LDL) 123 mg/dl. HDL-C, which was determined three years prior to this presentation was found normal. The patient was prescribed extended release nicotinic acid. Further workup performed showed the ratio of APO B/APO A1 0.36 and direct LDL 28 mg/dl. In the absence of genetic or more obvious secondary causes, we hypothesized that low HDL-C in this patient was due to paraprotein interference in vitro with the liquid homogenous HDL assay. Serum protein electrophoresis demonstrated normal IgG and IgA and an abnormally high IgM at 3510 mg/dl (57-266). A bone marrow biopsy revealed Waldenstrom macroglobulinemia. A diagnostic workup for an isolated low HDL-C unmasking the diagnosis of Waldenstrom macroglobulinemia has been rarely reported. Care must be taken when using the homogeneous method for direct measurement of HDL-C as artifactually undetectable HDL-C might result in the mismanagement of patients with paraproteinemia.

Acute Liver Injury Induced by Sitagliptin: Report of Two Cases and Review of Literature

We present two cases of acute liver injury associated with sitagliptin. The first case was a 58-year-old male with a history of poorly controlled type 2 diabetes mellitus and hyperlipidemia. Sitagliptin was added for better control of diabetes. After initiation of sitagliptin, the patients serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased gradually over a period of six months. The second case was a 44-year-old female with type 2 diabetes mellitus, and she experienced a more than ten-fold elevation in ALT and AST levels after starting sitagliptin therapy. Both patients did not have any history of alcohol abuse, acetaminophen use, or chronic liver disease. In the literature review, the reported magnitude of liver enzyme derangement with sitagliptin is generally mild and transient (two-fold upper limit of normal). We believed that the acute derangement of ALT and AST in our patients was due to sitagliptin since the ALT and AST normalized shortly after sitagliptin was discontinued and remained at baseline after resuming all other medications. Further research is needed to understand the mechanism of dipeptidyl peptidase 4 (DPP-4) inhibitors associated liver injury.

Third Ventricular Tumors: A Comprehensive Literature Review

Third ventricle tumors are uncommon and account for 0.6 - 0.9% of all the brain tumors. Tumors of the third ventricle are classified into primary tumors, such as colloid cysts, choroid plexus papillomas, and ependymomas, or secondary tumors, such as craniopharyngiomas, optic nerve gliomas, pineal tumors, and meningiomas. Third ventricular tumors are uncommon, and their treatment involves significant morbidity and mortality. The colloid cyst has a better surgical outcome and many approaches are available to achieve a complete cure. Choroid plexus papilloma is also a common tumor documented with its treatment majorly based on surgical resection. In addition to multiple treatment options for craniopharyngiomas, surgery is the most preferred treatment option. Ependymomas also have few treatment options, with surgical resection adopted as the first line of treatment.

Improvement of Chronic Idiopathic Urticaria With Levothyroxine: A Case Report and Review of Literature

There is an increased association between chronic urticaria (CU) and thyroid autoantibodies. We presented a case of a patient suffering from CU and newly diagnosed Hashimoto’s thyroiditis in which levothyroxine therapy completely resolved the symptoms of urticaria. A 58-year-old female with a past medical history of recurrent urticaria presented with complaints of fatigue and weight gain. Laboratory investigations showed a high thyroid stimulating hormone (TSH) level and a low free thyroxine (T4) level. She had elevated levels of antithyroid peroxidase (anti-TPO) and anti-thyroglobulin antibodies (anti-TG). She was diagnosed as a case of Hashimotos thyroiditis and started on levothyroxine therapy. She noticed that her uncontrolled recurrent urticaria started to get better and after a few months of therapy, she stopped taking her topical ointments and antihistamines. The reason for the association between positive serological tests for thyroid autoimmunity and CU is unclear. The resolution of chronic urticaria with levothyroxine in our patient with Hashimotos thyroiditis suggests a common underlying mechanism between the two pathologies.

Pheochromocytoma Secreting Large Quantities of Both Epinephrine and Norepinephrine Presenting with Episodes of Hypotension and Severe Electrolyte Imbalance

Pheochromocytoma is a rare tumor usually arising from the adrenal medulla (strictly speaking, those arising outside the adrenal gland are called paragangliomas). We report a case of pheochromocytoma presenting as orthostatic hypotension and electrolyte imbalance. A 51-year-old woman was admitted because of vomiting and chest pain. She had fluctuating blood pressure (BP) with episodes of orthostatic hypotension. Computed tomography pulmonary angiogram was performed to rule out pulmonary embolism; it showed a clear chest, but an incidental right suprarenal mass. The biochemical analysis supports the diagnosis of pheochromocytoma. Her electrolyte panel revealed persistently low potassium, calcium, and magnesium levels despite aggressive replacement. We speculated that hypotension was mainly due to vasodilatation caused by excess plasma epinephrine and prescribed doxazosin and a nonselective beta-adrenergic blocker which stabilized BP. The right adrenal tumor excised, and postoperatively she remained hemodynamically stable with no hypotensive episode. Laboratory data taken six weeks after surgery show normal 24-hour urine metanephrine and normetanephrine and normal serum magnesium and calcium levels. This case report highlights the variable presentation of pheochromocytoma. We also discuss the probable mechanisms of electrolyte imbalance in our case.

Hyperprolactinemia with Galactorrhea Due to Subclinical Hypothyroidism: A Case Report and Review of Literature

Hyperprolactinemia is a common finding in primary hypothyroidism, but increased prolactin in the setting of subclinical hypothyroidism (SCH) has been scarcely reported in the literature. This is a rare case of hyperprolactinemia due to SCH that resolved with thyroid hormone replacement therapy. The patient was not on any medications known to cause hyperprolactinemia but she was using isoniazid for her latent tuberculosis. Isoniazid therapy may explain breast pain, but there is no reported relationship between isoniazid use causing subclinical hypothyroidism and hyperprolactinemia. A literature review reveals that few cases of galactorrhea associated with subclinical hypothyroidism have been reported. Similar to the reported cases in the literature, our patient’s thyroid stimulating hormone (TSH) and prolactin levels returned to normal with levothyroxine therapy.

Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto’s Thyroiditis: A Case Report and Review of Literature

Hashitoxicosis is the initial hyperthyroid phase of patients with Hashimotos thyroiditis and, usually, this phase lasts for one to two months. We report a case of a 21-year-old male who had Hashitoxicosis of two years duration before converting to Hashimoto’s hypothyroidism. He initially presented with complaints of increased appetite, heat intolerance, fatigue, and sweating. On a physical exam, he had mild exophthalmos with lid lag and a fine tremor in the hands. Thyroid function tests also confirmed that the patient had hyperthyroidism. Thyroglobulin antibody and thyroid peroxidase antibody were both positive. He also had mildly elevated thyroid-stimulating immunoglobulin (TSI) but decreased radioactive iodine uptake scan. Based on the clinical presentation and biochemical test, a diagnosis of Hashitoxicosis was made. This hyperthyroid phase lasted for a period of two years. The patient eventually developed hypothyroidism suggesting that Hashimotos thyroiditis was the most likely diagnosis. He was started on levothyroxine replacement therapy and remained euthyroid on levothyroxine since that day. The initial presentation mimicked Grave’s disease, but with decreased radioiodine uptake, despite the high TSI level, leading us to treat him medically and not with radioactive iodine therapy. The patient was thus spared unnecessary radioactive iodine therapy (RAI) therapy.

Generalized Edema Caused by Albiglutide: A Case Report

Albiglutide is a long-acting glucagon‐like peptide‐1 (GLP-1) receptor agonist administered by weekly injection. Albiglutide-treated patients experience incidences of adverse effects, including cardiovascular, renal, and gastrointestinal symptoms and injection-site reactions. We report the first case of generalized edema induced by albiglutide. We present a 35-year-old female with type-2 diabetes. She developed generalized edema after the start of albiglutide. Her physical examination and all the laboratory tests, including thyroid function tests, albumin level test, and renal function test were unremarkable, and did not explain her generalized edema. Later on, her albiglutide was discontinued, which lead to the resolution of her edema. We conclude that her generalized edema could be due to a possible side effect of albiglutide.