Subhash Varma

Tropical pyomyositis (myositis tropicans): current perspective

Tropical pyomyositis, a disease often seen in tropical countries, is characterised by suppuration within skeletal muscles, manifesting as single or multiple abscesses. The most common organism implicated is Staphylococcus aureus. In 20%–50% of cases there is a history of trauma to the affected muscles. Commonly involved muscles are quadriceps, glutei, pectoralis major, serratus anterior, biceps, iliopsoas, gastrocnemius, abdominal and spinal muscles. Early diagnosis is often missed because of lack of specific signs, unfamiliarity with the disease, atypical manifestations, and a wide range of differential diagnosis. Diagnostic techniques like ultrasound and computed tomography/magnetic resonance imaging are very useful in diagnosis. The diagnosis is confirmed either by biopsy or aspiration of pus from the affected muscles. The initial antibiotic of choice is cloxacillin. Incision and drainage are important components of management. Treatment for Gram negative or anaerobic organisms should be instituted, whenever indicated. Physicians should become more familiar with this potentially life threatening but curable infective disease entity.

Pheochromocytoma associated with pregnancy: case report and review of the literature.

UNLABELLED We report on a young woman with pheochromocytoma associated with pregnancy and review 41 other cases reported in the literature from 1988 to 1997. This review reveals that the overall maternal mortality was 4 percent and the fetal loss 11 percent; antenatal diagnosis of pheochromocytoma reduced maternal mortality to 2 percent; however, fetal loss was 14 percent. Diagnosis of pheochromocytoma was made antepartum in 83 percent of the cases. Although pheochromocytoma associated with pregnancy is rare, a high index of clinical suspicion must be kept and all those at risk must be investigated to achieve an early diagnosis and improved outcome. Once the diagnosis is confirmed, alpha-adrenergic blockade is essential and beta-blockade may be required. Magnetic resonance imaging and computerized tomography scan may be used to localize the tumor during the antenatal period. In early pregnancy, i.e., before 24 weeks, both tumor resection and medical treatment are associated with good fetal outcome; in later pregnancy, elective cesarean delivery followed by tumor resection results in favorable maternal and fetal outcome. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the clinical manifestations of a pheochromocytoma during pregnancy, how to make the diagnosis of a pheochromocytoma during pregnancy, and to know the medical and surgical management of a pheochromocytoma during pregnancy.

Chemical warfare agents

Chemical warfare agents (CWAs) are defined as any chemical substance whose toxic properties are utilised to kill, injure or incapacitate an enemy in warfare and associated military operations. Chemical agents have been used in war since times immemorial, but their use reached a peak during World War I. During World War II only the Germans used them in the infamous gas chambers. Since then these have been intermittently used both in war and acts of terrorisms. Many countries have stockpiles of these agents. There has been a legislative effort worldwide to ban the use of CWAs under the chemical weapons convention which came into force in 1997. However the manufacture of these agents cannot be completely prohibited as some of them have potential industrial uses. Moreover despite the remedial measures taken so far and worldwide condemnation, the ease of manufacturing these agents and effectiveness during combat or small scale terrorist operations still make them a powerful weapon to reckon with. These agents are classified according to mechanism of toxicity in humans into blister agents, nerve agents, asphyxiants, choking agents and incapacitating/behavior altering agents. Some of these agents can be as devastating as a nuclear bomb. In addition to immediate injuries caused by chemical agents, some of them are associated with long term morbidities and psychological problems. In this review we will discuss briefly about the historical background, properties, manufacture techniques and industrial uses, mechanism of toxicity, clinical features of exposure and pharmacological management of casualties caused by chemical agents.

Invasive zygomycosis in India: experience in a tertiary care hospital

Aim: To report the natural history and clinical course of zygomycosis from a single tertiary care centre in India where doctors maintain an institutional zygomycosis registry. Methods: The clinical and laboratory data collected prospectively from patients with antemortem diagnosis for invasive zygomycosis, and retrospectively from autopsy diagnosed cases, over an 18 month period (July 2006–December 2007) were combined and analysed. Results: During the period 75 cases (50 cases/year) of zygomycosis were reported. Antemortem diagnosis could be made in 81% of cases and 9% of patients had nosocomial zygomycosis. The spectrum of disease included rhino-orbito-cerebral (48%), pulmonary (17%), gastrointestinal (13%), cutaneous (11%), renal and disseminated zygomycosis (5% each). Uncontrolled type 2 diabetes (58%) and diabetic ketoacidosis (38%) in the rhino-orbito-cerebral type, renal failure (69%) in the pulmonary type, prematurity (70%) in the gastrointestinal type, and breach of skin (88%) in cutaneous zygomycosis, were the significant (p<0.05) underlying illnesses. Rhizopus oryzae (69%) was the most common isolate followed by Apophysomyces elegans (19%). Overall mortality was 45% in patients who could be treated. Outcome was significantly poor when surgical debridement could not be performed or the patients were treated only with amphotericin B deoxycholate. On multivariate analysis, patients with a Glasgow Coma Score (GCS) ⩾9 had a better prognosis. Conclusions: Zygomycosis is a threat in uncontrolled diabetes. New risk factors such as renal failure and chronic liver disease require attention. A elegans is an emerging agent in India. The need for surgical debridement in addition to medical treatment is emphasised. GCS is an independent marker of prognosis in cases of invasive zygomycosis.

Regulatory T-cells in B-cell chronic lymphocytic leukemia: their role in disease progression and autoimmune cytopenias

Abstract Regulatory T-cells (Tregs) have been shown to be important for the balance of autoimmunity and oncogenesis. Tregs have a protective role in autoimmune diseases and conversely promote oncogenesis. Chronic lymphocytic leukemia (CLL) is unique in being at the cross-roads of oncogenesis and autoimmunity. We studied Tregs, defined as CD4+CD25highCD127lowFOXP3+, in 32 treatment-naive patients with CLL. Our study shows that patients with CLL had a higher absolute Treg count than the control group (p < 0.001). A progressive increase of Tregs was noted in advanced stages of the disease (p < 0.001). The increase in absolute Treg count is more significant than the increase in percentage Tregs. The absolute Treg count appears to be more important in disease pathogenesis. The absolute Treg count was significantly higher in those patients having autoimmune cytopenias. There was an inverse correlation between lymphocyte doubling time and absolute Treg count (p = 0.03). The absolute Treg count may be used as a prognostic marker in CLL.

Amoebic liver abscess in the medical emergency of a North Indian hospital.

BackgroundAmoebic Liver abscess although fairly common in developing countries, yet, there is limited data on the clinical presentation to the emergency department. A retrospective analysis of 86 indoor cases of Amoebic Liver Abscess presenting to the emergency department over a 5-year period was carried out.FindingsThe mean age of patients was 40.5 ± 2.1 years (male-female ratio = 7:1). Fever, pain abdomen and diarrhea were seen in 94%, 90% and 10.5% respectively. Duration of symptoms less than 2 weeks was seen in 48% cases. Hepatomegaly was present in 16% cases only, a right sided pleural effusion in 14% cases and ascites in 5.7%. On ultrasound, a right lobe abscess was seen in 65%, a left lobe abscess in 13% and multiple abscesses in both the lobes in 22% cases. Seventy one cases underwent per-cutaneous pigtail catheter drainage for a mean period of 13.4 ± 0.8 days. The mortality rate was 5.8%. On multivariate regression and correlation analysis, a higher number of inserted pigtail catheters correlated to mortality.ConclusionsAmoebic liver abscess presents commonly to the emergency department and should be suspected in persons with prolonged fever and pain abdomen. Conservative management for uncomplicated amoebic liver abscess and insertion of single per-cutaneous pigtail catheter drainage for complicated amoebic liver abscess are efficacious as treatment modalities.

Craniofacial zygomycosis caused by Apophysomyces elegans

Summary. A fatal case of craniofacial zygomycosis caused by Apophysomyces elegans in a 52‐year‐old man was diagnosed by the presence of broad aseptate, branched hyaline hyphae in tissue from paranasal sinuses and surrounding areas, and isolation of the fungus from the same tissue. The patient suffered from idiopathic myelofibrosis as underlying disease, he was thrombocytopenic and was mildly hyperglycaemic. The infection represents the second case of craniofacial zygomycosis due to A. elegans.

Maternal and perinatal outcome in idiopathic thrombocytopenic purpura (ITP) with pregnancy.

Background. Idiopathic thrombocytopenic purpura commonly affects women of childbearing age and is associated with maternal and fetal complications. Management of a pregnant patient is difficult and requires combined care of obstetrician and a neonatologist. We report our experience of idiopathic thrombocytopenic purpura during pregnancy during the last 7 years. Method. A retrospective study over the 7‐year period 1997–2003 was carried out in the Department of Obstetrics and Gynaecology in the Postgraduate Institute of Medical Education and Research, Chandigarh, India. The course of pregnancy, disease and perinatal outcome of 19 pregnancies in 16 patients with idiopathic thrombocytopenic purpura was studied. Results. Out of 16 patients with idiopathic thrombocytopenic purpura, eight were already diagnosed while the other eight were diagnosed during pregnancy. Five patients diagnosed during pregnancy had severe thrombocytopenia, and four of them showed hemorrhagic manifestation. Nine patients required steroids during pregnancy. Two patients received immunoglobulin therapy. During the antenatal period one patient developed pre‐eclampsia and one patient had gestational diabetes mellitus. Both of these patients were on steroids. There was no postpartum hemorrhage or maternal death. None of the neonates had bleeding complication, irrespective of mode of delivery. Conclusion. Pregnant patients with idiopathic thrombocytopenic purpura have generally good maternal and perinatal outcomes.

Can fluorodeoxyglucose positron emission tomography/computed tomography avoid negative iliac crest biopsies in evaluation of marrow involvement by lymphoma at time of initial staging?

Abstract The assessment of bone marrow involvement (BMI) is important for accurate prognostication and deciding the appropriate therapy in patients with lymphoma. Conventional bilateral iliac crest biopsies (ILBMBs) have many limitations. F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is a useful investigative tool for detecting BMI. F-18 FDG PET/CT data for 97 patients with either non-Hodgkin lymphoma (NHL) or Hodgkin lymphoma (HL) were analyzed. ILBMB was performed 7–10 days later. A final diagnosis of BMI was made in 38/97 patients on the basis of composite criteria derived from both FDG PET/CT and ILBMB results. ILBMB detected BMI in 29/38 patients, 2/5 patients with HL, 27/33 patients with NHL, 19/25 patients with aggressive NHL, and 8/8 patients with indolent NHL with a sensitivity of 76%, 40%, 82%, 76%, and 100%, respectively. FDG PET/CT was true positive for BMI in 5/5 patients with HL and 29/33 patients with NHL, comprising 25/25 patients with aggressive NHL and 4/8 patients with indolent NHL, with a sensitivity of 100%, 88%, 100%, and 50%, respectively. FDG PET/CT performed better than ILBMB in cases of HL and aggressive NHL, but its sensitivity was poor in cases of indolent lymphoma. In addition, FDG PET/CT had a very high negative predictive value approaching 100% in HL and aggressive NHL, which might help in avoiding negative ILBMBs.

Prognostic value of quantitative parameters derived on initial staging 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with high-grade non-Hodgkin's lymphoma.

ObjectivesThis study was carried out to evaluate the role of quantitative parameters in staging PET in predicting prognosis in patients with high-grade non-Hodgkin’s lymphoma (NHL). MethodsA total of 51 histopathologically proven high-grade NHL patients treated with conventional chemotherapy regimens were included in the study. Total lesion glycolysis (TLG) and functional volumes (FVs) were defined as per the PET Response Criteria in Solid Tumors (PERCIST) criteria. All patients were followed up for a minimum period of 1 year or until an event, whichever occurred earlier. ResultsOf the four semiquantitative parameters studied, SUVmax and SUVmean did not show a statistically significant correlation with progression-free survival or overall survival, whereas TLG and FV showed a weak but statistically significant negative correlation. Using the receiver operating characteristic curve analysis, optimal cut-offs were derived for FV and TLG to predict progression and death. Using the cut-off values of 416 cm3 and 3340 g for FV and TLG, respectively, a statistically significant difference in progression-free survival and overall survival was obtained in the groups with FV and TLG above and below the threshold. On multivariate analysis of all the conventional prognostic factors and TLG more than 3340 and FV more than 416 cm3, only age greater than 60 years (P=0.013) and FV more than 416 cm3 (P=0.012) were found to be independently associated with disease progression. ConclusionOur results indicate that FV and TLG in staging PET/CT could be useful indices in predicting outcomes in patients with high-grade NHL treated with standard first-line chemotherapy regimens.