Subhash Giri

Acute hepatic failure due to dengue: A case report

Dengue is an arboviral disease endemic in many parts of the world. Although it is known to cause hepatic involvement commonly, it only occasionally results in acute hepatic failure. We present the case of a young male who developed acute hepatic failure due to dengue. The differentials and the management is discussed.

Complicated malaria: a rare presentation of Plasmodium ovale.

Malaria has emerged as a major public health problem worldwide. Complications are commonly seen in Plasmodium falciparum (P. falciparum) and Plasmodium vivax (P. vivax) infection, but due to Plasmodium ovale (P. ovale) infection is rarely described in literature. Here we report a case of severe disease due to P. ovale infection complicated with jaundice, thrombocytopenia, hypotension and acute renal failure.

Longitudinal extensive transverse myelitis due to tuberculosis: A report of four cases

Tuberculosis of the central nervous system (CNS) accounts for approximately 1% of all cases of tuberculosis and half of these involve the spine. Intramedullary involvement is rare in tuberculosis and usually present in the form of radiculomyelitis, transverse myelitis, intraspinal granulomas, or thrombosis of anterior spinal artery. Transverse myelitis typically extends two or less spinal segments, whereas longitudinal extensive transverse myelitis (LETM) extends three or more spinal segments in length and may occasionally span all the segments of the spinal cord. LETM is most frequently associated with neuromyelitis optica (NMO). Moreover, associations between NMO and active pulmonary tuberculosis have been suggested by a number of case reports and case series. We present here four cases of spinal tuberculosis that presented with LETM and none of them had a clinical profile fulfilling the diagnostic criteria for NMO.

Concurrent reactive arthritis and myelitis – a case report

Reactive arthritis is a post infectious multisystem illness which usually occurs after episodes of diarrhoea or urinary tract infections. It can cause many manifestations other than the musculoskeletal system including skin, urogenital system and eyes. However the central nervous system is only occasionally involved. We discuss the case of a 32 year old male who presented with myelitis in association with reactive arthritis.

Luffa echinata: Healer plant or potential killer?

Bristly luffa (Luffa echinata), a member of the cucurbitaceae family is an Ayurvedic medicinal plant, which has been used in the traditional system of medicine for variety of symptoms. The active constituents like cucurbitacin, saponin, echinatin, β-Sitosterol, oleanolic acid and flavonoids have important pathophysiological effects on human body. However, there is no earlier published report of any toxicity on humans. We report a case of a 50-year-old gentleman, who presented with gastrointestinal bleeding, deranged liver function and shock following consumption of dried fruits of Luffa echinata soaked overnight in water. He had antral gastritis and duodenal erosions on upper gastrointestinal endoscopy and was managed conservatively and recovered completely.

Relationship of levels of Vitamin D with flow-mediated dilatation of brachial artery in patients of myocardial infarction and healthy control: A case-control study.

Background: Cardiovascular diseases (CVD) remain the leading cause of death worldwide. Vitamin D deficiency has been linked to increased risk of adverse CV events. Vitamin D deficiency may be responsible for endothelial dysfunction which in turn affects the onset and progression of coronary artery disease and its risk factors, directly or indirectly through various mechanisms. Materials and Methods: It was case–control study. A total of 50 cases of acute myocardial infarction (AMI) (aged 40–60 years), admitted to medicine emergency/CCU, were taken as per ACC/AHA 2007 guidelines. An equal number of age- and sex-matched controls were also taken. Risk factors of AMI, flow-mediated dilatation (FMD), and 25(OH)D levels were studied in all cases and controls. Correlation was also studied between FMD and 25(OH)D. Results: The mean values of FMD were 18.86 ± 5.39% and 10.35 ± 4.90% in controls and cases, respectively (P < 0.05). The endothelial dilatation after glyceryl trinitrate (GTN) was also studied and was found to be 26.175 ± 4.25% and 18.80 ± 5.72% in controls and cases, respectively (P < 0.05). The mean levels of 25(OH)D in controls and cases were 25.45 ± 12.17 and 14.53 ± 8.28 ng/ml, respectively. In this study, 56% of subjects were Vitamin D deficient, 25% were Vitamin D insufficient, and only 19% had Vitamin D in normal range. A positive correlation coefficient was found between FMD and 25(OH) Vitamin D levels (r = 0.841, P < 0.01). In this study, a positive correlation coefficient was also found between endothelial dilatation after GTN and 25(OH)D levels (r = 0.743, P < 0.01). Conclusion: In this study, it was found that FMD was markedly impaired in patients of AMI when compared to controls. It was also found that majority of the study population was Vitamin D deficient; however, the deficiency was more severe in patients of AMI. We also found out that FMD was positively correlated (r = 0.841) to the deficiency state of Vitamin D in all the study subjects.

Education and Imaging. Gastrointestinal: A cutaneous clue to painless acute on chronic pancreatitis.

A 50 year old male presented with nodular swellings on his lower limbs, buttocks, abdomen, chest and back for 15 days. He denied any history of abdominal pain or steatorrhea. He was a known hypertensive and a diabetic for three years. He had a history of chronic alcohol abuse (30 years). At presentation his vital signs were stable but he appeared pale. Multiple subcutaneous nodules of variable consistency were present in the lower limbs, abdomen and buttocks. The swellings on the buttock, back and upper chest wall were firm and tender (Figure 1A and B). The findings of fine needle aspiration cytology and biopsy of the cutaneous lesions revealed lobular panniculitis with foci of fat necrosis. In the areas of necrosis ghost adipocytes were also seen (Figure 2A and B). His investigations revealed low haemoglobin (Hb-7.8 gm/dL) with peripheral blood smear showing macrocytes, microcytes and hypersegmented neutrophils suggestive of combined deficiency anemia. His serum amylase was 2115 U/L and his lipase was 1870 U/L. Serum calcium was 7. 9 mg/dL. Serum triglyceride was 132 mg %. Contrast CT abdomen revealed changes of acute on chronic pancreatitis with evidence of a hypodense collection in the region of head, multiple calcifications and dilation of main pancreatic duct (Figure 3A and 3B). The patient was managed with conservatively and improved with resolution of pain and normalisation in levels of amylase. Panniculitis is inflammation in the adipose tissue which can result from numerous causes. Pancreatic panniculitis is a rare cause of panniculitis resulting from enzyme mediated saponification of fat. Some of the lesions may ulcerate and yield an oily secretion. Histopathology is characterised by a predominantly lobular panniculitis with foci of fat necrosis and an imflammatory infiltrate at periphery. Ghost adipocytes lack nuclei and have a basophilic cytoplasm due to calcium deposition secondary to saponification. Panniculitis is usually seen in the setting of pancreatitis or pancreatic neoplasms and its association with polyarthritis has been reported. Although it can accompany any pancreatic pathology, the prognosis depends on the underlying pancreatic illness. Occurrence at distant locations is possibly mediated through elevated serum amylase and lipase which have been found in the lesions. The present case is being reported for two reasons; firstly, panniculitis was the presenting manifestation of pancreatitis in this case and secondly, our patient had a painless pancreatitis which would otherwise be missed.

HIV-1 infection and erythroleukemia: a rare association.

/l over two years on ART. During one of her regular visits to the ART clinic, she complained of easy fatigability for 2 months. There was no history of fever, blood loss, malignancy or any history of exposure to ionizing radiation, toxins or chemotherapy. After she was detected having anemia, AZT was replaced by d4T in the dose of 30 mg bd and a detail clinical and laboratory workup was undertaken. Her clinical examination revealed severe degree of pallor, rest of the general and systemic examinations were normal. Her hemoglobin was 61 g/l, total leukocyte count was 41 × 10

Hypopituitarism presenting as congestive heart failure

Sheehans syndrome (SS) develops as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage and is characterized by various degrees of hypopituitarism. Although the occurrence of SS is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency any time following the event. Appropriate hormone replacement therapy results in marked clinical improvement. We present an unusual case of SS in a young lady who continued to have normal menstruation after the index event, had two spontaneous pregnancies, and was diagnosed only 11 years later when she presented to us with acute heart failure.

Unusual infectious mononucleosis complicated by vasculitis

Infectious mononucleosis (IM) is a clinical syndrome caused by Epstein-Barr virus (EBV). It manifests as fever, pharyngitis, malaise, adenopathy, and atypical lymphocytosis. Cardiovascular complications are thought to be rare in IM. There are very few case reports of EBV-associated vasculitides, like Kawasaki disease and systemic polyarteritis nodosa, however, involvement of the large caliber arteries like the aorta and its branches have been reported only scarcely. Myocarditis also is rare as an early manifestation of EBV infection. We present here a rare case of IM, presented initially with acute myocarditis and later with large-vessels arteritis.