Meera Ekka

Early versus delayed initiation of antiretroviral therapy for Indian HIV-Infected individuals with tuberculosis on antituberculosis treatment.

BackgroundFor antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events.MethodsIn a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART.FindingsA total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar.InterpretationEarly initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability.Trial registrationCTRI/2011/12/002260

Alzheimer disease in post-menopausal women: Intervene in the critical window period.

Alzheimer disease (AD) is a crippling neurodegenerative disorder. It is more common in females after menopause. Estrogen probably has a protective role in cognitive decline. Large amount of research has been carried out to see the benefits of hormone replacement therapy with regards to Alzheimer still its neuroprotective effect is not established. Recent studies suggest a reduced risk of AD and improved cognitive functioning of post-menopausal women who used 17 β-estradiol in the critical period. Use of 17 β-estradiol in young and healthy post-menopausal women yields the maximum benefit when the neurons are intact or neuronal stress has just started. Hence intervention in the critical period is key in the prevention or delay of AD in post-menopausal women.

Nevirapine versus efavirenz-based antiretroviral therapy regimens in antiretroviral-naive patients with HIV and tuberculosis infections in India: a pilot study

BackgroundAdministration of rifampicin along with nevirapine reduces the plasma concentration of nevirapine in human immunodeficiency virus positive individuals with concomitant tuberculosis (HIV-TB patients). Nevirapine is a much cheaper drug than its alternative efavirenz, and might be beneficial in resource constrained settings.MethodsA randomised open label trial was conducted at All India Institute of Medical Sciences, New Delhi, India. During the regimen of an antiretroviral therapy (ART), naive HIV-TB patients were randomly assigned to receive either nevirapine or efavirenz based ART with concomitant rifampicin based anti-tubercular therapy (ATT). Participants were followed for 24 months after starting ART. The end points were virological, immunological and clinical responses, and progression of HIV disease marked by failure of ART.ResultsOf the 135 HIV-TB patients, who were receiving rifampicin based ATT, 68 were selected randomly to receive efavirenz based ART and 67 to receive nevirapine based ART. The virological failure rates in the overall population, and the nevirapine and efavirenz groups were 14.1% (19/135); 14.9% (10/67) and 13.2% (9/68), respectively (p = 0.94). No significant difference was found between the groups in the rate of clinical, immunological or virological failures. The overall mortality was 17% with no significant difference between the two groups. Except for the lead in period on day 14, the mean nevirapine concentration remained above 3 mg/L. No association was found between plasma levels of nevirapine and incidence of unfavourable outcomes in this group.ConclusionsOutcome of ART in HIV-TB patients on rifampicin based ATT showed no significant difference, irrespective of whether efavirenz or nevirapine was used. Therefore, nevirapine based ART could be an alternative in the resource limited settings in patients with HIV and tuberculosis co-infection.Trial registrationNCT No. 01805258.

Cardiac tamponade as initial presenting feature of primary hypothyroidism in the ED.

Pericardial effusion is commonly detected in patients with severe hypothyroidism and is typically mild; rarely, it may lead to cardiac tamponade. Cardiac tamponade with myxedema coma as initial presenting feature of previously unrecognized hypothyroidism is rare. This case highlights that previously undiagnosed hypothyroidism can manifest as myxedema coma with shock due to pericardial tamponade particularly in winters because a cold environment can precipitate myxedema.We report an undiagnosed case of primary hypothyroidism who presented to the emergency department for the first time with both cardiac tamponade and myxedema coma. This combination of cardiac tamponade and myxedema coma as the presenting features of primary hypothyroidism has rarely been reported in the literature. The patient was effectively managed with echocardiography-guided pericardiocentesis, levothyroxine, and external rewarming. Cardiac tamponade and myxedema coma as presenting features of previously unrecognized primary hypothyroidism are extremely rare. Urgent bedside echocardiography with pericardiocentesis along with thyroxine therapy is the treatment of choice. It is important to include hypothyroidism as the differential diagnosis in patients with cardiac tamponade and altered level of consciousness especially in winter months.

Successful flexible bronchoscopic management of a large-sized aspirated partial denture.

A 48-year-old male patient presented to the emergency room with a history of chest pain and breathlessness. Chest X-ray demonstrated a large radio-opaque foreign body in relation to the proximal right bronchial tree. The patient subsequently revealed a history of a misplaced denture 4 months previously. Urgent flexible bronchoscopy (FB) examination demonstrated a large partial denture impacted in the right intermediate bronchus, which was removed successfully using a flexible bronchoscope. Although rigid bronchoscopy (RB) is the procedure of choice for large-sized and impacted airway foreign bodies, the present case highlights the utility of FB in airway foreign body removal. In clinically stable patients with foreign body inhalation, FB can be employed initially as it is an outpatient and cost-effective procedure which can obviate the need for administration of general anaesthesia.

The antiretroviral efficacy of highly active antiretroviral therapy and plasma nevirapine concentrations in HIV-TB co-infected Indian patients receiving rifampicin based antituberculosis treatment

BackgroundRifampicin reduces the plasma concentrations of nevirapine in human immunodeficiency virus (HIV) and tuberculosis (TB) co-infected patients, who are administered these drugs concomitantly. We conducted a prospective interventional study to assess the efficacy of nevirapine-containing highly active antiretroviral treatment (HAART) when co-administered with rifampicin-containing antituberculosis treatment (ATT) and also measured plasma nevirapine concentrations in patients receiving such a nevirapine-containing HAART regimen.Methods63 cases included antiretroviral treatment naïve HIV-TB co-infected patients with CD4 counts less than 200 cells/mm3 started on rifampicin-containing ATT followed by nevirapine-containing HAART. In control group we included 51 HIV patients without tuberculosis and on nevirapine-containing HAART. They were assessed for clinical and immunological response at the end of 24 and 48 weeks. Plasma nevirapine concentrations were measured at days 14, 28, 42 and 180 of starting HAART.Results97 out of 114 (85.1%) patients were alive at the end of 48 weeks. The CD4 cell count showed a mean increase of 108 vs.113 cells/mm3 (p=0.83) at 24 weeks of HAART in cases and controls respectively. Overall, 58.73% patients in cases had viral loads of less than 400 copies/ml at the end of 48 weeks. The mean (± SD) Nevirapine concentrations of cases and control at 14, 28, 42 and 180 days were 2.19 ± 1.49 vs. 3.27 ± 4.95 (p = 0.10), 2.78 ± 1.60 vs. 3.67 ± 3.59 (p = 0.08), 3.06 ± 3.32 vs. 4.04 ± 2.55 (p = 0.10) respectively and 3.04 μg/ml (in cases).ConclusionsGood immunological and clinical response can be obtained in HIV-TB co-infected patients receiving rifampicin and nevirapine concomitantly despite somewhat lower nevirapine trough concentrations. This suggests that rifampicin-containing ATT may be co administered in resource limited setting with nevirapine-containing HAART regimen without substantial reduction in antiretroviral effectiveness. Larger sample sized studies and longer follow-up are required to identify populations of individuals where the reduction in nevirapine concentration may result in lower ART response or shorter response duration.

Retropharyngeal abscess as a rare presentation of pulmonary tuberculosis.

A tubercular retropharyngeal abscess is rare in immunocompetent adults. In the case of a tubercular retropharyngeal abscess, it is usually due to cervical spine tuberculosis and is seen mostly in children. A 19-year-old female patient presented to our Medicine Outpatient Department (OPD) at All India Institute of Medical Sciences (AIIMS) with odynophagia and neck pain for two months, without any other constitutional symptoms. On evaluation, she was diagnosed with tubercular retropharyngeal abscess along with pulmonary tuberculosis, without involvement of the cervical spine. This patient was successfully treated by antituberculosis drug therapy alone, without any need for surgical drainage.

Hydration therapy: critical intervention in the ED to prevent stroke in evolution after acute ischemic stroke

ous experience in the creation of IO route can successfully perform this practice, even in his/her first experience, provided that he/she properly reads or learns the practice. As a result of this study, which enlightened the use of IO route of administration, demonstrated the usefulness of IO route of administration, revealed the learning curve, and, in addition, aimed to minimize to complications due to the incremental use of IO route of administration, we think that the physicians without a previous experience in this practice can practically and safely create an IO route of administration after the eighth practice, after performing the first 3 or 4 practice under the supervision of experienced physicians.

Ventricular tachycardia – an atypical initial presentation of sarcoidosis: a case report

IntroductionSymptomatic cardiac involvement is seen in less than 5% of all cases of sarcoidosis. Although clinically apparent cardiac sarcoidosis is an uncommon entity, ventricular tachyarrhythmias as the first presenting symptom are very rare.Case presentationWe discuss the case of a 41-year-old Asian woman who presented to our hospital with intermittent palpitation and on evaluation was diagnosed to have systemic sarcoidosis with cardiac involvement. She was started on multiple antiarrhythmic drugs and corticosteroids without any satisfactory response.ConclusionsOur case report indicates that sarcoidosis can manifest as ventricular tachycardia without any detectable systemic findings. This makes sarcoidosis an important diagnostic consideration in patients with ventricular tachycardia of unknown origin given the high mortality associated with ventricular tachyarrhythmias.

Severe hypoglycemia masquerading as cerebellar stroke

Hypoglycemia is a common presenting feature of diabetes in the emergency department. Cardiovascular and neuroglycopenia features are well documented in the literature. We here report a case of 55-year-old female who came to our emergency with clinical features suggestive of cerebellar stroke. Laboratory investigations revealed severe hypoglycemia. The cerebellar signs and symptoms improved completely with intravenous dextrose infusion. Her MR imaging and Doppler of carotid and vertebrobasilar arteries were noncontributory. Hypoglycemia causes behavioral changes, confusion, loss of consciousness, and seizures. It is also well known to cause hemiplegia and aphasia. Hypoglycemia presenting as cerebellar stroke is rarely reported in the literature. This case highlights an uncommon manifestation of a common clinical condition. Physician must rule out hypoglycemia in every stroke patients.