Manas Ghosh

Study of Vitamin B 12 deficiency and peripheral neuropathy in metformin-treated early Type 2 diabetes mellitus

Background: Long-term therapy with metformin was shown to decrease the Vitamin B12 level and manifested as peripheral neuropathy. Aim: The aim of this study is to define the prevalence of Vitamin B12 deficiency in early Type 2 diabetic patients (duration ≤5 years or drug treatment ≤3 years) and the relationship among metformin exposure and levels of cobalamin (Cbl), folic acid, and homocysteine (Hcy) with severity of peripheral neuropathy. Methodology: This is a cross-sectional study involving randomly selected ninety patients (male 56, female 34) between age groups of 35 and 70 years, comparing those who had received >6 months of metformin (Group A) (n = 35) with those without metformin (Group B) (n = 35) and patients taking metformin with other oral hypoglycemic agent (Group C) (n = 20). Comparisons were made clinically, biochemically (serum Cbl, fasting Hcy, and folic acid), and with electrophysiological measures (nerve conduction studies of all four limbs). Comorbidities contributing to neuropathy were excluded from the study. Results: Group A patients (54.28%) were prone to develop peripheral neuropathy comparing Group B (28.57%) and Group C (35%). There was significantly low plasma level of Cbl in Group A (mean 306.314 pg/ml) than in Group B (mean 627.543 pg/ml) and Group C (mean 419.920 pg/ml). There was insignificant low-level plasma folic acid in Group A (16.47 ng/ml) than in Group B (16.81 ng/ml) and Group C (22.50 ng/ml). There was significantly high level of Hcy in Group A (mean 17.35 µmol/L) and Group C (mean 16.99 µmol/L) than in Group B (mean 13.22 µmol/L). Metformin users even for 2 years showed evidence of neuropathy on nerve conduction velocity though their body mass index and postprandial blood sugar were maintained. There was significant difference in between groups regarding plasma Cbl, folic acid, and Hcy level as significance level <0.05 in all three groups (F [2, 87] = 28.1, P = 0.000), (F [2, 87] = 7.43, P = 0.001), (F [2, 87] = 9.76, P = 0.000). Post hoc study shows significant (P < 0.05) lowering of Cbl and Hcy level in Group A (mean = 306.314, standard deviation [SD] = 176.7) than in Group C (mean = 419.92, SD = 208.23) and Group B (mean = 627.543, SD = 168.33). Discussion: Even short-term treatment with metformin causes a decrease in serum Cbl folic acid and increase in Hcy, which leads to peripheral neuropathy in Type 2 diabetes patients. A multicenter study with heterogeneous population would have increased the power of the study. We suggest prophylactic Vitamin B12 and folic acid supplementation or periodical assay in metformin user.

Correlation of intracranial atherosclerosis with carotid stenosis in ischemic stroke patients

Introduction: Carotid stenosis is a major risk factor for ischemic stroke. However, the effect of carotid stenosis on the site of stroke is still under investigation. Aims: This study aimed to elucidate how the presence of carotid stenosis influenced the pattern of stroke and also how it interacted with other risk factors for stroke. Materials and Methods: Thirty-eight patients with ischemic stroke were included in this study and were investigated with carotid artery Doppler and magnetic resonance angiography for carotid stenosis and intracranial stenosis in the circle of Willis, respectively. Other known risk factors of stroke were also studied in and compared between the subgroups with and without carotid stenosis. Results: In patients without carotid stenosis, anterior cerebral artery was the commonest site of stenosis. In patients with carotid stenosis, middle cerebral artery was the commonest site of stenosis. Overall, middle cerebral artery was the commonest territory of stroke. Patients with hypertension, diabetes and history of smoking had preferential stenosis of the anterior cerebral artery.

Cortical Venous Thrombosis due to Familial AT-III Deficiency Presenting with Seizures

Cortical venous thrombosis is a rare but treatable condition of the central nervous system which can manifest with bizarre signs and symptoms. However, a prompt clinical suspicion which can be confirmed by a T2 weighted MR image followed by venography is immediately needed to assess the patient and start therapy. We report a case of familial anti-thrombin III deficiency in a young male who presented to us with seizures. Successful treatment of this patient holds promise of an essentially non curable neurological condition.

Systemic Lupus Erythematosus Presenting as Mitral Valve Prolapse

424 Manas Ghosh1, Kaushik Ghosh1, Ambarish Bhattacharya2, Mrinal Pal3, Sisir Chakraborty4, Susmita Ghosh5 Department of 1Medicine and 5Anaesthesiology, Murshidabad Medical College and Hospital, West Bengal, India; 2Department of Medicine, Charnok Hospital, Kolkata; 3Department of Biochemistry, Burdwan Medical College and Hospital, West Bengal; 4Department of Medicine, College of Medicine and Sagore Dutta Hospital, Kolkatta, West Bengal, India. Systemic Lupus Erythematosus Presenting as Mitral Valve Prolapse JOURNAL OF CASE REPORTS 2016;6(3):424-427

The dengue fever and its complication: A scenario in a tertiary-level hospital of greater Kolkata

Background: India experienced a massive outbreak of dengue fever in the 2012-2013 period and this outbreak shows significantly different distribution across India. It also envisaged the hidden weakness of prevention and control program of vector-borne diseases. Aim and Objective: This study was designed to characterize the clinical and demographical profiles of this outbreak in a tertiary-level hospital of greater Kolkata. Materials and Methods: A descriptive hospital-based observational study was conducted among diagnosed dengue fever patients admitted at a tertiary-level hospital during the dengue outbreak in the 2012-2013 period. The clinical, biochemical, and demographic data of those patients were collected and recorded in a planned structured format. Results: The data of a total 382 dengue patients were analyzed. Out of these 382 patients, 67.8% are males and 42.1% belongs to 20-40 years age group. The mean and median ages of the study group were 37.39 (±17.70) years and 35 years, respectively. The mean (±SD) duration of hospital staying was 4.9 (±1.90) days. Out of these patients, 19.4% had hemorrhagic rash throughout the body, 13.2% presented with hemorrhage, and 8.6% were comorbid with typhoid immunoglobulin M (IgM) positive. Clinical shock, peripheral edema, and pulmonary edema were documented in 6.3%, 2.6%, and 5.3% of the patients, respectively. Ultrasonography (USG) abdomen test revealed that 15% of the patients had thick-walled gallbladder, while 11.27% had ascites. Out of the 382 patients, 26.3% (101) presented with pleural effusion, and 10.5% patient′s platelet count went below 35,000. The alanine transaminase (ALT), alkaline phosphatase, and lipase level were abnormally increased in 82.7%, 17.1%, 29.6% patients, respectively. Conclusion: Suburban as well as rural area′s people, mainly the young males, were mostly affected in this outbreak. Enteric fever was found with comorbid infection among a few dengue patients. Some patients documented with deferent complications, which were managed by early diagnosis and supportive treatment.

Prevalence of skin changes in diabetes mellitus and its correlation with internal diseases: A single center observational study

Background and Aim: This single-center observational cross-sectional study has been done in an attempt to find out the prevalence of various skin manifestations in diabetes patients (DM) and their correlation with diabetes control and complications. Materials and Methods: Skin manifestations present over 12 months among those attend diabetes clinic were included in the study. Apart from demographic data and type, patients were also screened for micro vascular complications and control of diabetes over last 3 months. Results and Discussion: Sixty (n = 60) diabetes patisents (Type 1 DM, 9 patients and Type 2 DM 51 patients) have been found to have various skin lesions. Thirty-one (51.67%) patients presented with infectious conditions, vascular complications were present in 21 (35%) and dermatomes belonging to the miscellaneous group were present in 50 (83.33%) patients. Pyoderma, diabetic dermopathy, and pruritus without skin lesions were found to be most common manifestations in infective, vascular and miscellaneous group, respectively. Higher level of HB1AC was found in patient with diabetic bulla (10.5 ± 0), scleredema (9.75 ± 0.77), lichen planus (9.3 ± 1.6), and acanthosis nigricans (9.15 ± 0.89). Patients with psoriasis and vitiligo had statistically significant lower level of glycosylated hemoglobin (P =< 0.001 and 0.03, respectively). However, no association of any kind of skin manifestation with DM with other microangiopathic complications was found in this study.

A commonly overlooked motor neuron disease mimicker

Summary Motor neuron disease (MND) is a progressive devastating neurodegenerative disease, which universally progresses towards death. Hence, every attempt should be made to find out if there are any treatable conditions, which can mimic MND. Herein, we describe a case of hypercalcaemia due to primary hyperparathyroidism confused as MND and subsequently cured with parathyroid surgery. Learning points Any patient with neurological disorder should have a screening of all the common electrolytes including calcium as electrolyte imbalance can present with paralysis (e.g. hypokalaemia) to amyotrophic lateral sclerosis (e.g. hypercalcaemia). No patient should be stamped as having MND without having a proper work-up of all its differentials as there might be a treatable condition masquerading as MND.

A 22-year-old patient presenting with seizures and migratory pulmonary infiltrates

A 22-year-old male patient presented with a fever for the previous 10 days, breathlessness with dry cough for the previous 3 days and decreased urine output since the morning of admission. His history was unremarkable. He denied any history of joint pain, rashes, eye symptoms, haemoptysis or sinus disease and there was no history of illicit drug abuse. He was a nonsmoker with no history of alcohol intake and was not on any regular medications. Clinical examination revealed icterus, blood pressure of 130/85 mmHg, tachycardia (130 beats·min−1), tachypnoea (30 breaths·min−1) and a temperature of 39°C. His upper airways were normal on examination and there were reduced breath sounds and crackles at the right lung base. The rest of the system examinations was unremarkable. Initial relevant investigations are summarised in table 1. The capillary blood glucose was 117 mg·dL−1. His typhoid and dengue serology along with dual malarial antigens were all-negative. An electrocardiogram showed sinus tachycardia. View this table: Table 1 Initial investigations Arterial blood gases on air showed type 1 respiratory failure with a pH of 7.39, an oxygen tension ( P O2) of 56 mmHg, a carbon dioxide tension ( P CO2) of 32 mmHg, bicarbonate 25 mmol·L−1 and lactate of 2.9 mmol·L−1. Urine dipsticks showed 1+ proteinuria. A chest radiograph was performed (fig. 1). Figure 1 Chest radiography Task 1 What does the chest radiograph show? Answer 1 The chest radiograph shows right and left lower zone patchy consolidation. A diagnosis of community-acquired pneumonia was made and he was started on high-flow oxygen at 8 L·min−1 with mask, intravenous fluids and empirical antibiotics (penicillin with macrolide) after sending blood cultures for analysis. On the second day of admission, the patient developed generalised tonic clonic seizures in the early morning and was started on intravenous phenytoin. However, seizures …