Sk Dham

PLASMA CELL MYELOMA PRESENTING AS ACUTE CONSTIPATION

Plasma cell myeloma or multiple myeloma is an uncontrolled proliferation of plasma cells in the marrow. The neoplastic cells synthesise abnormal amount of monoclonal immunoglobulins or alpha or lambda light chains [1]. Clinical manifestations of myeloma vary and include bone pains, hypercalcaemia, anaemia, hypogammaglobulinemia, and spinal cord compression etc. [1, 2]. We report here one such case who had an unusual presentation of acute constipation. Case Report A 45-year-old male patient first presented with acute constipation and pain rectal region of 3 days duration. Initially he attributed it to acute exacerbation of fissure-in-ano which he developed 5 years ago. However, clinical examination including per rectal and proctoscopic examination was normal. For next 5 days he was managed with repeated glycerine enema and laxatives but without any relief. At this stage he was subjected to a detailed evaluation. Endoscopic examination of colon, stomach and duodenum failed to detect any abnormality. He was also evaluated for underlying psychiatric disorder but without any positive finding. In view of intractability of symptoms he was referred to us on eleventh day of his illness. A detailed history revealed that at onset he had transient vague pain over the chest at the level of nipple for 2 days. He also gave history of numbness and paraesthesia over lower limbs and hesitance for micturition of 3 days duration. There was no history of pain in the spine or other bones, fever, headache, weight loss, recurrent infections, bleeding diathesis or trauma. There was no history of hypertension, diabetes mellitus or tuberculosis in the past. Clinical examination revealed him to be obese with height 165 cms and weight 80 kgs. There was no pallor, lymphadenopathy or bony tenderness. Neurological examination revealed hypoaesthesia below D6 dermatome (right side being affected more than left side) and weakness in lower limbs. Deep tendon reflexes were sluggish in lower limbs. Abdominal reflexes and plantar reflexes were absent on both sides. There was no papilloedema or signs of meningeal irritation. Tenderness was present over D4 and D5 spine. Examination of other systems was within normal limits. Investigations revealed Hb 12.4 gm per cent, TDLC 6700/cmm with P 59 L38 M2 E1 per cent, ESR 120 mm fall first hour, blood urea 29 mg per cent, serum creatinine 1.0 mg per cent, blood uric acid 8.0 mg per cent and serum calcium 9 mg per cent. Radiograph of chest PA view and 12-lead electrocardiogram were normal. Radiograph of skull, pelvis and long bones in the limbs showed multiple punched out lytic lesions. Scrum electrophoresis showed monoclonal gammopathy, Monoclonal (M) spike in the beta-gamma interzone alongwith hypoalbuminemia and hypogammaglobulinemia. Bone marrow study showed marked infiltration by plasma cells (>30%) with reduction in erythroid and myeloid cells. Magnetic resonance imaging (MRI) of spine demonstrated altered signal intensity of D4-D6 vertebrae. There was an intraspinal soft tissue mass on right side extending from D2 to D5 vertebrae compressing the spinal cord and thecal sac anterioly at that level. There was a paraspinal extension of the mass through intervertebral foramina at D3-4, D4-D6. Radionuclide bone scan showed patchy increased uptake in skull, spine, ribs and major bones of the limbs suggestive of extensive skeletal involvement. Diagnosis of multiple myeloma with myeloradiculopathy was made. He was managed with palliative chemotherapy (vincristine, cyclophosphamide, adriamycin, steroids) and radiotherapy. However, his condition rapidly deteriorated and he died 3 months later.

MANAGEMENT OF KALA AZAR – AN UPDATE

Kala azar continues to be a medical problem in India and with the increase in incidence of HIV Infection it is likely that kala azar will be encountered more frequently and in its atypical forms. To aid diagnosis, several immunological tests are now available and they are more sensitive and specific than the aldehyde test. Like many other diseases today, the treatment of kala azar is hampered by drug resistance. Newer drugs are available and so are new delivery systems. Kala azar develops frequently in the HIV infected person before development of AIDS. The presentation is atypical and leishmanial species other than L. donovani may also be the infecting agents. A combination of sandfly control, detection and treatment of patients and prevention of drug resistance continues to the ideal approach for the control of the disease.

CARDIOVASCULAR RISK FACTOR CLUSTERING AND CORONARY ARTERY DISEASE : A 4-YEAR FOLLOW UP STUDY OF 257 SERVICE PERSONNEL

Two hundred and fifty seven service personnel with established diagnosis of (a) silent ischaemia (40.47%) (b) Q-infarction (25.68%) and (c) non-Q-infarction (33.85%) along with 50 age-matched controls were subjected to stress tests before and after identification and control of risk factors. Lack of exercise (63.0%), dietetic indiscretion (47.4%) and cigarette smoking (40.4%) were the main risk factors. Hypercholesterolaemia (22.1%), alcohol over-indulgence (17.1%), positive family history (16.3%), diabetes mellitus (9.7%) and hypertension (6.2%) were other contributing factors. Clustering or multiplicity of risk factors was seen in 61.1% cases. All patients were advised for control of risk factors along with necessary specific therapy wherever indicated. Initial stress test was positive in 83.3% of the total and on repetition, after 4 years, the positivity dropped to 45.9% with a rate of improvement of 44.9%. Patients with silent ischaemia showed the maximum improvement (57.8%) following the risk factor intervention. Only 4 cases (1.56%) showed deterioration with reinfarction during the 4-year follow up.

LEUKAEMIC INVOLVEMENT OF CENTRAL NERVOUS SYSTEM

Eighty two patients of leukaemia consisting of 25 cases of acute lymphocytic leukaemia, 38 cases of acute myeloid leukaemia, 14 cases of chronic myeloid leukaemia and 5 cases of chronic lymphocytic leukaemia were evaluated for central nervous system (CNS) involvement. Speech disorders, cranial nerve palsies, encephalopathy, ataxia, intracranial haemorrhage, peripheral neuropathy and spinal cord involvement were the main neurological findings detected in 23 (28.1%) cases. All except one were subjected to autopsy after death. Leukaemic infiltrations (36.6%) and intracranial haemorrhage (26.8%) were the prominent CNS autopsy findings. In addition, demyelination with astrocytosis (9.7%) and gliosis (2.4%) were seen. In all, 45 (54.9%) of the patients showed CNS involvement at autopsy. Thus a large number of CNS lesions were missed clinically and detected only on autopsy.

MICROSOMAL AND THYROGLOBULIN ANTIBODIES IN THYROID DISORDERS

Eighty patients with various thyroid disorders and 20 controls were investigated to determine antibodies against thyroglobulin and microsomal antigens by haemagglutination and immunofluorescent techniques. They were also tested for immunoglobulin profile by radial immunodiffusion methods. Patients with Hashimotos disease, idiopathic hypothyroidism, and Graves disease showed significant elevations of IgG. None of the patients with toxic nodular goitre or thyroid adenoma showed any thyroid antibodies while 69.2% patients with Graves disease, 16% with euthyroid goitre, 58.3% with hypothyroidism and all the patients with Hashimotos disease had microsomal antibodies by immunofluorescent test. Similarly, all the cases of Hashimotos disease, 41.6% of those with hypothyroidism, 30% of Graves disease patients and none of the patients with toxic nodule or thyroid adenoma had thyroglobulin antibodies by haemaglutination test. Evaluation for auto-antibodies may aid the clinician in the overall assessment of various thyroid disorders.

EFFICACY OF SUCRALFATE IN PREVENTING GASTROINTESTINAL SIDE EFFECTS OF NSAIDs

To find out the efficacy of sucralfate in preventing gastrointestinal side effects of non-steroidal anti-inflammatory drugs (NSAIDs) a prospective, randomised single blind study was conducted from 1989 to 1992. Patients with osteoarthritis, rheumatoid arthritis and other long standing painful conditions, who were expected to receive NSAIDs for over three months, were recruited into the study. All medicines were discontinued for a period of 10-15 days prior to initial endoscopic assessment. NSAID therapy was started and the patients were randomised to receive either placebo (group A) or sucralfate (group B) in addition. Patient were reassessed clinically every week and an endoscopic examination was repeated after 6-8 weeks of follow-up. A total of 176 patients were studied in group A (n=91) and group B (n=85). At the end of 8 weeks gastrointestinal symptoms were present in 30.6% and 26.4% patients of group A and B respectively. Endoscopic assessment showed superficial lesions in 36.5% and 18.7% while endoscopic ulcer in 2.4% and 1.1% patients of groups A and B respectively. Thus in patients receiving chronic NSAID therapy, simultaneous administration of sucralfate reduces the incidence of superficial gastric lesions but has no significant effect on symptoms or ulcer formation.

IS EARLY AMBULATION SAFE IN VIRAL HEPATITIS

To derermine if early ambulation was safe in acute viral hepatitis (AVH), 202 patients of uncomplicated AVH were prospectively randomised into two group. Group A (n=100) received conventional treatment with bed rest while group B (n=102) patients were ambulated as soon as their clinical symptoms abated and progressive clinical and biochemical recovery was noted. While mean recovery time in two groups was not significantlly different (28.8 vs 29.7 days), bed rest period in group B was significantly less (28.8 vs 8.6 days). Natural history of the AVH, clinical and biochemical findings and relapse rate over a follow up period of 14 to 16 months, were no different in the two groups. None of the patients developed chronic hepatitis. Early ambulation is there fore safe in uncomplicated AVH and can lead to enormous saving of manhours and hospital resources.

PULMONARY EMBOLISM – AN ENIGMA

Pulmonary embolism is considered a rare disease in India. The diagnosis is likely to be missed as its presentation is often enigmatic. Ten cases of pulmonary embolism are presented. Nine patients presented with acute pulmonary embolism, while one had chronic pulmonary emboli with cor pulmonale. The diagnosis was based on pulmonary angiography (1 case), lung perfusion/ventilation scan (2 cases), autopsy (2 cases) and characteristic ECG, X-ray chest and clinical features (5 cases). The initial diagnosis was often incorrect (7/10 cases). Common presenting clinical features were: sudden breathlessness (10/10), tachypnoea (10/10) and tachycardia (8/10); chest pain (3/10) was uncommon and hemoptysis was not seen in any patient. ECG revealed isolated sinus tachycardia in 2 cases, S1 Q3 T3 pattern in 2, and right axis with ST-T wave changes in 5 patients. X-ray chest showed either an area of oligemia or non-specific opacities in 7 patients and was normal in three cases. Advances in specific diagnostic modalities coupled with heightened awareness should contribute to an early detection of pulmonary embolism, rarity of which may be more apparent than real.

ANEURYSM OF SINUS OF VALSALVA DISSECTING INTO THE INTERVENTRICULAR SEPTUM – ECHOCARDIOGRAPHIC DIAGNOSIS (A Case Report)

Aneurysm of sinus of Valsalva dissecting into interventricular septum is a rare entity. We report one such case who was incidentally diagnosed by echocardiography to have this abnormality during evaluation of a clinically suspected isolated aortic regurgitation.

ROLE OF LEFT VENTRICULAR FUNCTION EVALUATION IN NON SPECIFIC ECG ABNORMALITY

A total of 373 subjects [367 service persons and 6 civilians) with ECG abnormality were evaluated with maximal TMT exercise, 86 (23%) of them showing positivity. Subsequent assessment including radionuclide ventriculography and coronary arteriography wherever necessary revealed coronary artery disease in 31 (8.3%). The remaining 55 were further evaluated by 2D and M-Mode echocardiography for exclusion of any other cardiac disease responsible for the ECG abnormality as well as for assessment of LV performance. Seven subjects showed minor structural cardiac anomalies - MVP in 5 and HOCM in 2. The remaining 48 showed no significant difference in the measurements of LV posterior wall and IV septal wall thickness, mitral septal separation, mitral valve excursion velocities, LV end-systolic/end-diastolic internal diameters and calculated percent fractional shortening, LV end-diastolic, end-systolic and stroke volumes as well as ejection fraction, on comparison with 20 age matched controls. These 48 service persons, thus evaluated were considered to have no organic heart disease or cardiac function impairment and were cleared for all strenuous duties including flying of sophisticated aircrafts or posting to high altitudes.