Kolar Vishwanath Vinod

A fatal case of thiacloprid poisoning

Neonicotinoid insecticides are considered to be less toxic to humans compared to older insecticides such as organophosphates, carbamates, pyrethroids, and organochlorine compounds. However,reports of severe human toxicity with neonicotinoids are emerging. Acute human thiacloprid poisoning and death as a result have not been reported in the literature so far. Here we report a case of thiacloprid poisoning resulting from deliberate ingestion in a 23-year-old man, manifesting with status epilepticus, respiratory paralysis,rhabdomyolysis, metabolic acidosis, and acute kidney injury (AKI), and ultimately giving rise to refractory shock and death. Thiacloprid can cause fatal human toxicity when ingested heavily, and absence of an effective antidote raises concern in this regard.

Dapsone hypersensitivity syndrome: A rare life threatening complication of dapsone therapy.

Dapsone can cause several adverse effects, the most serious being dapsone hypersensitivity syndrome (DHS), which is potentially fatal. Here we report a case of severe, life threatening dapsone systemic hypersensitivity syndrome in a 17-year-old male who presented with high grade fever, eosinophilia, lymphadenopathy, skin rash, hepatitis and encephalopathy, which was managed successfully with oral steroids. The case is being reported to emphasize the need for timely diagnosis and prompt treatment of this rare complication for successful outcomes. DHS is also reviewed in brief.

High dose intravenous immunoglobulin may be complicated by myocardial infarction

Intravenous immunoglobulin [IVIg] is useful for treating several clinical conditions and is largely considered safe, without major adverse events. Here we report a case of acute ST elevation myocardial infarction associated with high dose IVIg administration in a previously healthy 69-year-old male patient of Guillain Barre syndrome. The case is being reported to emphasize the need for treating physicians to be aware of thrombotic complications associated with IVIg. The thrombotic complications associated with IVIg are reviewed in brief, and the measures to reduce them are discussed.

Snakebite, dysautonomia and central nervous system signs

### Learning Point for Clinicians This report highlights that clinically significant and striking dysautonomia can rarely occur in elapid snakebites and when present in the absence of clear history of snakebite, can cause diagnostic confusion with other mimickers of neuroparalytic snakebite such as myasthenic crisis, Grave’s disease, botulism, Guillain–Barre syndrome and acute porphyria. One early morning in August 2011, a previously healthy girl of 17 years was brought to the emergency medicine department of our hospital with history of sudden onset drooping of upper eyelids, diplopia, difficulty in speaking, swallowing and breathing and weakness of limbs for 2 h. These symptoms were preceded by abdominal pain and vomiting. She was apparently alright the previous night and had slept outside her kutcha house on the ground. There was no history of similar illness in family or deliberate self-poisoning. On admission, she was found to be unconscious, cyanosed with poor respiratory efforts. Pupils were normal and reactive to light. She was intubated immediately and mechanically ventilated. After an …

A rare cause of dural venous sinus thrombosis.

position, a skin incision from just posterior to the greater trochanter to the middle of the buttock was made. The piriformis muscle was exposed by the blunt dissection of the gluteus maximus muscle. The sciatic nerve was then exposed under the piriformis muscle [Figure 2a]. The piriformis muscle was tight and tense especially on internal rotation of the hip joint. The piriformis muscle was incised at the tendinons portion with which the tension of the piriformis muscle decreased and compression over the sciatic nerve got relieved [Figure 2b]. There was no apparent pus discharge intraoperatively. After the surgery, she had dramatic relief of pain. She returned to her work as a nurse 2 months after the surgery. Follow‐up MR and CT images showed normalized right piriformis muscle [Figure 1c and d].

Near fatal spontaneous intraperitoneal bleeding: A rare manifestation in a congenital factor X deficiency carrier

Congenital factor X (FX) deficiency is a rare coagulation disorder of autosomal recessive inheritance, characterized by bleeding of variable severity. Bleeding severity generally correlates with the level of FX functional activity and severe bleeding usually occurs in moderate and severe deficiency, when FX coagulant activity is <5%. FX activity above 10% is infrequently associated with severe bleeding. Here we report the rare occurrence of life-threatening massive spontaneous intraperitoneal bleeding with hypovolemic shock, resulting from spontaneous rupture of an ovarian luteal cyst in a 25-year-old FX deficiency carrier woman, with a FX activity of 26%. She was managed successfully conservatively, with fresh frozen plasma and packed red blood cell transfusions and she showed gradual improvement. The case is being reported to discuss the diagnosis and management of this rare inherited coagulation disorder.

Exploring circulatory shock and mortality in viper envenomation: a prospective observational study from India

Background Viper envenomation contributes to nearly 50% of snake-bite deaths in India, chiefly due to circulatory shock. The mechanisms leading to circulatory shock include bleeding, capillary leak syndrome (CLS) and myocardial depression. Pituitary-adrenal axis involvement in circulatory shock, though described, has not been fully elucidated. Aim To identify predictors of circulatory shock and mortality in viper envenomation and explore the role of pituitary-adrenal axis in circulatory shock. Design Prospective hospital-based observational study. Methods Once a syndromic diagnosis of viper envenomation was made, relevant clinical and laboratory data were collected. Serum cortisol was estimated in those with circulatory shock. Post-mortem examination of pituitary, kidneys and adrenals was performed. Adjusted odds-ratios were calculated for respective risk-factors for shock and mortality using multivariable logistic regression with backward elimination strategy. Results Of 248 patients of viper envenomation treated at our hospital, circulatory shock was present in 19% and in-hospital mortality was 23%. CLS, circulatory shock, bleeding and requirement of > 20 vials of antivenom predicted mortality. Ischaemic and haemorrhagic necrosis of pituitary or adrenals was present in 51% of post-mortem specimens. Disseminated intravascular coagulation (DIC) and CLS were strong predictors of pituitary haemorrhage. Conclusion Predictors of mortality - bleeding, CLS and requirement of high antivenom doses are warning signs which can alert clinicians to patients who may have poor outcomes. Our study points to a definite role of pituitary-adrenal axis in circulatory shock supports the hypothesis that pituitary involvement in viper envenomation closely resembles Sheehan syndrome. The mechanism of pituitary involvement appears to be a result of increased susceptibility of the swollen gland secondary to CLS and micro thrombi deposition in DIC.

“Whip Lash” Skin Lesions Caused by Bleomycin Therapy

A 43-year-old man had presented in October 2016 with fever, weight loss and enlarged right cervical lymph nodes for 5 months. He was diagnosed with classical Hodgkin lymphoma (stage-IIIB) and was started on Adriamycin, Bleomycin, Vinblastine and Dacarbazine chemotherapy. In February 2017, 10 days after completion of fourth cycle of ABVD chemotherapy, he was noted to have asymptomatic, linear (flagellate), hyperpigmented skin lesions resembling ‘‘whip lashes’’ over the trunk (Fig. 1), upper and lower limbs. Bleomycin was omitted from subsequent two cycles of chemotherapy. Bleomycin toxicity involves mainly lungs and skin. Dermatologic adverse effects reported with bleomycin include hyperkeratosis, alopecia, Raynaud’s phenomenon, palmoplantar desquamation/ulceration, eczematoid/sclerodermoid lesions, nailbed changes and the characteristic, albeit rare flagellate rash [1]. Flagellate rash is a doseindependent adverse effect characterized by linear, intermingled, erythematous streaks resembling ‘‘whip lash’’ marks. There is no characteristic distribution and rash may involve face, trunk and extremities. The rash may resolve completely or heal with hyperpigmentation, which may persist longer. The rash has been suggested as a fixed drug eruption resulting from bleomycin extravasation and accumulation in skin. Rash may follow bleomycin use for

Comparison of Hemoglobin A1c with fasting and 2-h plasma glucose tests for diagnosis of diabetes and prediabetes among high-risk South Indians

Background: Glycosylated hemoglobin (HbA1c) has not been evaluated extensively for diabetes and prediabetes diagnosis and short-term variability of fasting plasma glucose (FPG), 2-h PG post-75 g glucose load (2 hPG) and HbA1c has not been studied among Indians. Objectives: The study aimed to compare the sensitivity of HbA1c, FPG and 2 hPG for diabetes and prediabetes diagnosis as per the American Diabetes Association criteria, assess short-term variability of three tests and determine optimal HbA1c cutoffs for diabetes and prediabetes diagnosis among high-risk south Indians. Methods: This diagnostic accuracy study, conducted at a tertiary care teaching hospital located in South India, enrolled 332 adults at high risk for diabetes and subjected them to testing (FPG, 2 hPG, and HbA1c) twice at 2–3 weeks interval. Sensitivity of three tests for diagnosing diabetes and prediabetes was determined based on the final diagnosis of normoglycemia/prediabetes/diabetes made with six test results for each participant. Optimal HbA1c cutoffs for diabetes and prediabetes were determined based on the final diagnosis of glycemic status made with four test results of FPG and 2 hPG. Results: FPG, 2 hPG, and HbA1c, at American Diabetes Association recommended values, had sensitivity of 84.4%, 97%, and 93.8% respectively for diabetes diagnosis. HbA1c had lowest short-term variability (CVw = 1.6%). Receiver operating characteristic curve plotted with mean (of two values) HbA1c for each participant showed optimal HbA1c cutoffs of 6.5% for diabetes (area under curve [AUC] =0.990, sensitivity = 95.8%, specificity = 96.2%, accuracy = 95.2%) and 5.9% for prediabetes (AUC = 0.893, sensitivity = 84.3%, specificity = 80%, accuracy = 75.6%) diagnosis respectively. HbA1c <5.6% had 100% negative predictive value to exclude prediabetes/diabetes. Conclusions: HbA1c ≥6.5% is a convenient and reliable alternative to plasma glucose tests to diagnose diabetes among high-risk South Indians. HbA1c ≥5.9% is optimal for prediabetes diagnosis and value <5.6% excludes prediabetes/diabetes.

Clinical profile & complications of neurotoxic snake bite & comparison of two regimens of polyvalent anti-snake venom in its treatment

Background & objectives: The optimal anti-snake venom (ASV) dose required to treat neurotoxic snake envenomation is not known. Low-dose ASV (national protocol: maximum dose 200 ml) may be as efficacious as the conventional regimen (100 ml six hourly till all symptoms disappear), but a direct comparison of the regimens is not available. The aim of this study was to test the efficacy of low-dose ASV regimen against the conventional high-dose regimen. Methods: The clinical profile of 51 patients with neurotoxic snake envenomation was studied. Patients were treated with either the national protocol or the conventional protocol for ASV administration. The time to complete recovery of symptoms, duration of mechanical ventilation and total dose of ASV were compared. Results: More patients were females (28 vs. 23) bitten in the early morning hours (2400-0600 h). Thirty nine of 51 (76.4%) patients required mechanical ventilation. In terms of progression of neuroparalysis, time to complete resolution of ptosis and occurrence of VAP and ASV reactions, there was no difference. Duration of mechanical ventilation was less with the national protocol (24 vs. 43.5 h). Significantly less amount of ASV was used with the national protocol (224 vs. 982 ml) per patient. There were no mortality or permanent neurological sequelae with either regimen. Interpretation & conclusions: In this preliminary study, it was found that the national ASV protocol was as effective as the conventional regimen for neurotoxic snake bites. However, the findings need to be tested in a larger randomized controlled trial for definitive conclusions.