Mahesh Prakash

Spontaneous perforation of pyometra in a cervical cancer patient: a case report and literature review

Abstract Pyometra is an uncommon condition with an incidence of less than 1% in gynaecologic patients. Spontaneous rupture of pyometra in cervical cancer presenting as generalized peritonitis is very rare. Only four cases have been described in the English literature to the best of our knowledge and from a PubMed search. The index case is an elderly postmenopausal female who was diagnosed with cervical cancer, started on radiotherapy and presented with features of generalized peritonitis. Contrast-enhanced CT revealed uterine perforation at the fundus with multiple abdominal and pelvic collections. A brief review of all the cases of ruptured pyometra in cervical cancer in the literature and a discussion of the role of imaging is presented.

Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy

Purpose. To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET). Methods. 25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor. Results. At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs. 31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p<0.001). Conclusion. Leukocyte-poor (type-4) PRP injection for recalcitrant LET enabled good improvement in pain and function.

Surgicel Granuloma: Unusual Cause of “Recurrent” Mass Lesion After Laparoscopic Nephron-sparing Surgery for Renal Cell Carcinoma

We present the first clinical report of Surgicel granuloma after laparoscopic nephron-sparing surgery and present the characteristics of this radiological image mimicking local recurrence. A 47-year-old man underwent laparoscopic nephron-sparing surgery for left renal interpolar incidentaloma; Surgicel bolsters were used for hemostasis. Histological examination revealed conventional clear-cell renal cell carcinoma with negative surgical margins. Magnetic resonance imaging at 3 months revealed a 2.5-cm enhancing mass in the region of nephron-sparing surgery. Computed tomography-guided core biopsy revealed foreign-body granuloma. Serial magnetic resonance imaging showed a decrease in the size/enhancement of the lesion during 12 months. To conclude, Surgicel may invoke foreign-body reaction leading to formation of pseudotumor, which leads to diagnostic dilemma.

Microbial profile and utility of soft tissue, pus, and bone cultures in diagnosing diabetic foot infections.

OBJECTIVE This study assessed the utility of pus, soft tissue, and bone specimens in diagnosing diabetic foot infections and the spectrum of the microbial flora and in vitro susceptibility to antibiotics. SUBJECTS AND METHODS This prospective study was carried out in 60 consecutive patients with diabetes having clinically infected foot ulcers. Detailed history, physical examination, and investigation were carried out to diagnose the presence of osteomyelitis and the microbial etiology of foot ulcers. Foot ulcers were classified as per Wagners classification. Soft tissue, pus, and bone samples were obtained and cultured for aerobic and anaerobic bacteria, and antimicrobial susceptibility testing was carried out as per the standard protocol. RESULTS Causative bacteria were isolated in 55 of 60 patients, and 157 isolates were cultured from 117 specimens with an average of 1.34 isolates per cases; however, the number of isolates per specimen did not differ among the various types of samples (P=0.78). Pus and soft tissue had predominantly polymicrobial flora, whereas bone infections were monomicrobial. The isolates from soft tissue specimens were different from those from bone and pus in 57% and 54% of cases, respectively. The common bacterial isolates from 117 specimens included Escherichia coli (21%) and Proteus species (15.9%). Nearly 70% of Staphylococcus aureus isolates were methicillin sensitive. All S. aureus and Enterococcus isolates were sensitive to vancomycin. Susceptibility of Gram-negative organisms to ciprofloxacin was 50%. CONCLUSIONS Diabetic foot infections are mostly polymicrobial with Gram-negative predominance. Multiple sampling from superficial and deep tissues, including bone, when involved, yields more relevant information diagnostically and therapeutically.

Percutaneous cyanoacrylate glue injection into the renal pseudoaneurysm to control intractable hematuria after percutaneous nephrolithotomy.

We report a case of a 43-year-old man who developed intractable hematuria after percutaneous nephrolithotomy. Angiography detected a pseudoaneurysm arising from the lower polar artery; however, embolization could not be performed because of unfavorable vascular anatomy. A percutaneous thrombin injection under ultrasound guidance initially controlled the bleeding, but hematuria subsequently recurred as a result of recanalization of the aneurysm. The case was successfully managed with ultrasound- and fluoroscopic-guided direct injection of cyanoacrylate glue into the pseudoaneurysm.

Assessment of premature atherosclerosis in systemic lupus erythematosus patients with and without nephritis

Background Risk of subclinical atherosclerosis is increased in patients with systemic lupus erythematosus (SLE). We correlated carotid intima media thickness (CIMT) and endothelial dysfunction through flow-mediated dilation (FMD) in SLE patients with the SLE Disease Activity Index (SLEDAI). Methods This single-centre cross-sectional study recruited 100 consenting SLE outpatients (ACR 1997 criteria) out of which 50 had nephritis, with disease duration of ≥2 years for SLE and ≥6 months for lupus nephritis. We measured baseline laboratory levels, CIMT and FMD (after brachial BP cuff inflation up to 200 mmHg for five minutes), and calculated SLEDAI. Results Mean age was 29.88 ± 6.53 years; 95/100 were female. CIMT showed positive correlation (p = 0.037; rho = 0.209), and FMD showed inverse correlation with patient’s age (p = 0.011; rho = –0.252). CIMT and FMD were more deranged in patients aged ≥25 years (p < 0.05). CIMT was not significantly different between SLE patients with and without nephritis (p > 0.05), whereas SLEDAI and FMD were more deranged in nephritis patients (p < 0.05). In patients without nephritis, FMD showed significant inverse correlation with disease duration (p = 0.043; rho = –0.288) and urine albumin (p = 0.045; rho = –0.285). In nephritis patients, the correlation between age of the patient was significantly positive with CIMT (p = 0.001; rho = 0.441) and significantly inverse with FMD (p = 0.028; rho = –0.312). Conclusion SLE patients with nephritis are at a higher risk to develop arterial stiffening, leading to early end-organ damage. Early aggressive treatment may prevent endothelial dysfunction. FMD using vascular ultrasonography on the brachial artery represents a non-invasive, repeatable and useful method for the assessment of endothelial dysfunction.

Solitary skeletal metastasis in carcinoma gallbladder: two case reports

Abstract We report 2 cases of carcinoma gallbladder with only solitary skeletal metastasis. To the best of our knowledge there are only 3 case reports of carcinoma gallbladder with skeletal metastasis in the English literature.

Congenital atresia of portal vein with portocaval shunt associated with cardiac defects, skeletal deformities, and skin lesions in a boy

Congenital absence of portal vein is a rare anomaly that results from aberrant venous development in early embryonic life. The intestinal and splenic venous drainage bypass the liver and may drain directly into inferior vena cava or the left renal vein or the left hepatic vein. This rare anomaly is commonly associated with other congenital malformations and generally limited to females. We describe a rare case of aberrant portal vein development with congenital portocaval shunt (end-to-side) in a 3.5-year male child associated with cardiac defects (atrial and ventricular septal defects), skeletal deformities (flexion deformity and clinodactyly of digits and toes), and lichen planus with café au lait macules of skin.

Aspergillus endocarditis in a known case of allergic bronchopulmonary aspergillosis: an autopsy report

Invasive aspergillosis is an emerging infection mainly affecting immunocompromised patients. Aspergillus endocarditis remains a rare infection and usually occurs following cardiac surgery for prosthetic valves. This is an uncommon case of a 60-year-old asthmatic male who developed allergic bronchopulmonary aspergillosis during the course of his illness, and while receiving low dose oral steroids, he subsequently developed right-sided Aspergillus mural and native valvular endocarditis with extensive invasive pulmonary aspergillosis.

Carotid, aorta and renal arteries intima‑media thickness in patients with sporadic idiopathic hypoparathyroidism

Background: Alteration in homeostasis of calcium, phosphate and parathyroid hormone (PTH) predispose to vascular calcification that increases the risk of cardiovascular morbidity and mortality. The data on this aspect are scarce in patients with sporadic idiopathic hypoparathyroidism (SIH). Objective: The aim was to assess the effect of altered calcium, phosphate and PTH homeostasis in patients with SIH on intima media thickness (IMT), a surrogate marker of increased vascular risk. Methods: In this case–control study, we measured carotid IMT (CIMT), aortic IMT (AIMT) and renal arteries IMT (RIMT) in 30 consecutive patients with SIH, and compared with healthy subjects. IMT was measured by ultrasound by a single operator blinded to subjects details. Results: CIMT, AIMT, RIMT values in patients with SIH were significantly more than healthy subjects (0.60 ± 0.08 mm vs. 0.52 ± 0.09 mm, P = 0.001; 0.73 ± 0.09 mm vs. 0.65 ± 0.10, P = 0.004; and 0.34 ± 0.04 mm vs. 0.30 ± 0.05, P = 0.003, respectively). Clinical or biochemical parameters did not correlate with CIMT, AIMT and RIMT in patients with SIH. Conclusion: The vascular risk is increased in patients with SIH as assessed by CIMT, AIMT, and RIMT.