Rita Sood

Medical education in India

Medical schools in India produce the largest number of doctors than anywhere else in the world (30,408 from 271 medical schools), corresponding to the rapid proliferation of medical colleges in the last two decades, especially within the private sector. The Medical Council of India (MCI), the regulatory body, is required to approve any significant reforms in medical curricula. The accreditation process for medical schools focuses largely on the infrastructure and human resources required and little on the process and quality of education or outcomes. The implementation of the recommendations of MCI regarding recognition or de-recognition of a medical college is governed by the Ministry of Health and Family Welfare, whilst individual universities also have variable sets of regulations for their affiliated medical schools. As a result, there is no uniformity in the standard of medical education across the country.

Cytologic Diagnosis of Pulmonary Nocardiosis

Background Nocardiosis is an uncommon infection and presents as an opportunistic infection in an immunocompromised host. Pulmonary infection by Nocardia may be difficult to diagnose based on clinical and radiologic features, as these are not specific. Sputum examination, bronchoalveolar lavage and transthoracic ultrasound/ computed tomography-guided fine needle aspiration cytology offer a simple means of procuring material for diagnostic evaluation. Very few articles have described the morphologic appearance of this uncommon pathogen in cytologic material. Cases Three cases occurred in patients with an underlying immunocompromised state. Patient 1 was on steroid therapy for nephrotic syndrome, patient 2 was on immunosuppressant therapy after renal transplantation, and patient 3 was HIV positive. A diagnosis of pulmonary nocardiosis was suspected on Papanicolaou stain. Modified Ziebl-Neelsen stain and silver methanamine stains were useful in confirming the diagnosis. Conclusion A high index of suspicion for nocardiosis must be maintained while assessing cytologic material in immunosuppressed individuals as it may be masked by the intense inflammatory exudate associated with this infection. A meticulous search may reveal the presence of delicate, thin, faintly stained, branching filaments of Nocardia on routine Papanicolaou stain. Special stains and culture studies are useful in confirming the diagnosis.

Sarcoidosis Manifesting as Massive Splenomegaly: A Rare Occurrence

Sarcoidosis is a multisystemic granulomatous disease of unknown origin occurring worldwide and affecting people of all races and ages. This disease manifests most frequently with bilateral hilar lymphadenopathy, pulmonary infiltrates, and skin and ocular lesions. Granulomatous inflammation of the spleen is common in patients with sarcoidosis, but splenic enlargement is unusual and massive splenomegaly quite rare. Splenomegaly is usually homogeneous, but multiple low-attenuating nodular lesions are occasionally seen and easily mistaken for lymphoma, metastases, or infections such as tuberculosis. We describe an unusual case of sarcoidosis in a woman who presented with massive splenomegaly with extensive nodularity that cleared completely with corticosteroid therapy.

Immune Thrombocytopenia in a Challenging Case of Disseminated Tuberculosis: A Case Report and Review of the Literature

Mycobacterium tuberculosis (MTB) continues to predominate the cause of morbidity, and mortality in the developing world. The disease affects all the organ systems, and presents in various pathologic disease states. We report an uncommon manifestation of this rather common infectious disease in a 19-year-old male. Immune-mediated thrombocytopenia occurring as a consequence of the tuberculosis infection itself is an exceedingly rare occurrence, and at the time of writing of this paper, only 15 such published reports exist in the English literature so far.

Effect of Progressive Resistance Exercise Training on Hepatic Fat in Asian Indians with Non-Alcoholic Fatty Liver Disease

Introduction: Nonalcoholic fatty liver disease (NAFLD) is closely associated with obesity and insulin resistance and lifestyle measures form the cornerstone of therapy. Objective: To study the effect of progressive resistance training (PRT) on hepatic fat Research Article British Journal of Medicine & Medical Research, 4(1): 114-124, 2014 115 content, body composition and insulin sensitivity in patients with NAFLD. Methods: This study included 24 adult patients with NAFLD diagnosed on ultrasonography. Subjects with alcohol intake >140 gm/week and any secondary cause of fatty liver were excluded. Patients underwent thrice weekly sessions (40 minutes each) of resistance exercises including flexion at biceps, triceps, and hip flexion, knee extension and heel rise for 12 weeks. Preand post-intervention evaluation included anthropometry, BIA analysis, short insulin tolerance test (SITT), lipid profile and hepatic fat quantification by MRI. Results: Twenty four patients (17 males, 7 females, mean age 39.8±10.5 yrs) completed the study protocol with 78.7% compliance to PRT protocol. There was significant decrease in waist, hip and mid-thigh circumferences and skinfold thicknesses at biceps, triceps, subscapular and suprailiac regions (p<0.05), with no significant change in BMI and WHR. Insulin sensitivity improved significantly at 12 weeks as indicated by increase in k-value (rate of change of glucose) on SITT (0.84 vs 1.3, p=0.002). A decrease in total cholesterol and LDL-c with increase in HDL-c was noted after 12 weeks (p<0.05). Hepatic fat content also decreased at 12 weeks (22.3±3.9 vs 21.4±4.0 %, p=0.01). Conclusion: Moderate intensity PRT is associated with significant improvement in hepatic fat, truncal subcutaneous fat and insulin sensitivity in patients with NAFLD.

Scrub Typhus and Leptospirosis: The fallacy of Diagnosing with IgM Enzyme Linked Immunosorbant Assay

Introduction: Leptospirosis and scrub typhus are important causes of acute febrile illness in India. IgM Enzyme Linked Immunosorbant Assay (ELISA) is the most common diagnostic modality used for their diagnosis. The common epidemiology of both the diseases creates an opportunity of dual infections with these diseases. Therefore, the objective of the study was to detect and evaluate the cases of serological and molecular dual infections. Methodology: A cross sectional diagnostic study from October 2013 to October 2015 was conducted on 258 patients with acute febrile illness. All the samples were subjected to IgM ELISA for scrub typhus and leptospirosis. The samples that were positive for both scrub typhus and leptospirosis were subjected to serological tests for other infections. They were also subjected to PCR assays to find out the cases of molecular dual infections. Results: A total of twenty serum samples were positive by IgM ELISA for leptospirosis while thirty five serum samples were positive by IgM ELISA for scrub typhus. Among these, ten samples were positive for both the serological tests. These dual positives were additionally positive by serology for some other infections [Dengue (n = 2), Mycoplasma pneumoniae (n = 1), Malaria (n = 1), Chlamydia pneumoniae (n = 6), Typhoid (n = 2) and Legionella pneumophila (n = 1)]. Only one case of molecular dual infection was confirmed. Conclusion: The possibility of serological co-infections should be investigated in endemic areas. In a case of serological dual infection, since there are high chances of serological cross reactivity, molecular confirmation should be sought for. The choice of therapy in inconclusive cases should include those drugs that cover for both the infections.

Disseminated cryptococcosis with adrenal and lung involvement in an immunocompetent patient.

Disseminated cryptococcosis usually occurs in immunocompromised patients. Occasionally, it affects immunocompetent persons and mimics tuberculosis in clinical presentation and radiological findings. Usually, it affects lungs and central nervous system. Rarely, it may affect adrenal glands. We present a case of 65-year-old gentleman with prolonged pyrexia. Computed Tomography (CT) scan of chest and abdomen showed miliary pattern in the chest with bilateral adrenal masses. On the basis of clinical and radiological findings, the case was initially diagnosed as disseminated tuberculosis and anti tubercular treatment was started. Subsequently, on histopathological examination, the diagnosis was confirmed as disseminated cryptococcosis. Even in a country with high prevalence of tuberculosis, other causes of miliary mottling should be considered and histopathological examination should be sought.

Diagnostic utility of fluorodeoxyglucose positron emission tomography/computed tomography in pyrexia of unknown origin

Purpose of the Study: The present study was undertaken to evaluate the diagnostic utility of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) in patients presenting as pyrexia of unknown origin (PUO). Materials and Methods: Forty-seven patients (31 males and 16 females; mean age of 42.7 ± 19.96 years) presenting as PUO to the Department of Medicine at the All India Institute of Medical Sciences, New Delhi over a period of 2 years underwent F-18 FDG PET/CT. PET ⁄ CT was considered supportive when its results correlated with the final definitive diagnosis. Final diagnosis was made on the basis of combined evaluation of history, clinical findings, investigations, and response to treatment. Results: Thirty-five PET/CT studies (74.5%) were positive. However, only 18 (38.3%) were supportive of the final diagnosis. In three patients (6.4%), PET/CT was considered diagnostic as none of the other investigations including contrast-enhanced computed tomography of chest and abdomen, and directed tissue sampling could lead to the final diagnosis. All these three patients were diagnosed as aortoarteritis. Conclusion: Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography is an important emerging modality in the workup of PUO. It supported the final diagnosis in 38% of our patients and was diagnostic in 6.4% of patients. Thus, PET/CT should only be considered as second-line investigation for the diagnostic evaluation of PUO; especially in suspected noninfectious inflammatory disorders.

T-cell lymphoma masquerading as extrapulmonary tuberculosis: case report and review of literature

It is often difficult to establish confirmatory diagnosis in cases of extrapulmonary tuberculosis (TB) because of its paucibacillary nature and difficulty in accessing the involved organs. In several cases, empirical anti-tubercular treatment is started, and the patient is followed-up closely for response. In countries with high prevalence of TB, it is a reasonably good strategy and works most of the times. However, catastrophe may occur when aggressive lymphomas masquerade as TB.

Case of methaemoglobinaemia caused by tree oils and kerosene

We report a case of a young man who allegedly consumed 100 mL of an indigenous pesticide which is used for the killing of rats in households in India. The constituents were azadirachtin oil (40%), tea oil (15%), pine oil (25%) and kerosene oil (20%). He presented to us with shortness of breath and altered sensorium and was found to have fMetHb (fraction of methaemoglobin) level of 80%, which has been postulated to have a fatal outcome. He responded to a low dose of methylene blue along with intravenous vitamin C and the level of fMetHb came down to 20% within 1 hour. His sensorium improved markedly with a decrease in fMetHb to non-toxic levels and he was discharged 5 days after admission. A literature review pertaining to these constituents individually or in combination causing methaemoglobinaemia is discussed in the context of this case.