Sudhagar Mookkappan

Transient adrenal insufficiency and post-treatment bradycardia in scrub typhus - a case report.

Scrub typhus appears throughout the Asia-Pacific rim. This disease is known for its diverse clinical manifestations and complications. There is no literature on the association of scrub typhus with adrenal insufficiency. Relative bradycardia has been reported in scrub typhus during the febrile phase but not during convalescence. We report the case of a 45- year-old woman with scrub typhus whose blood pressure was persistently low due to acute adrenal insufficiency. Adrenal failure responded to supplementation with steroids. She also developed sinus bradycardia during the afebrile period following treatment.

Selective myelosuppression following yellow phosphorus ingestion.

Toxicity from accidental and intentional ingestion of yellow phosphorus, ubiquitously present in fireworks and rodenticides, has recently become more frequent. Gastrointestinal, renal, neurologic, and cardiovascular manifestations are common, with mortality of 23 per cent to 73 per cent. Reports of haematological abnormalities are rare. We report only the second case of severe neutropenia secondary to selective myelosuppression in a 14-year-old girl following intentional ingestion of yellow phosphorus. Leucocyte counts recovered spontaneously without further complications. Our case indicates that, besides hepatic and renal function monitoring, physicians should meticulously monitor blood counts in such cases for early detection of marrow suppression. Further studies are required to elucidate the complex mechanisms and significance of this unusual toxicity of yellow phosphorus.

Hemophagocytic lymphohistiocytosis in association with primary cutaneous anaplastic large cell lymphoma.

Hemophagocytic lymphohistiocytosis (HLH) has a well known association with lymphomas, especially of T cell origin. Prognosis of lymphoma associated HLH is very poor, especially in T cell lymphomas; and, therefore, early diagnosis might alter the outcome. Though association of HLH with systemic anaplastic large cell lymphoma (ALCL) is known, its occurrence in primary cutaneous ALCL (C-ALCL) is distinctly rare. We aim to describe a case of C-ALCL (anaplastic lymphoma kinase (ALK)−) in an elderly male who succumbed to the complication of associated HLH, which was possibly triggered by coexistent virus infection. We briefly present the literatures on lymphoma associated HLH and discuss the histopathological differentials of cutaneous CD30+ lymphoproliferative disorders. We do suggest that HLH may pose diagnostic challenges in the evaluation of an underlying lymphoma and hence warrants proper evaluation for the underlying etiologies and/or triggering factors.

Hemothorax in scrub typhus: A rare clinical manifestation

Scrub typhus is one of the most common causes of acute febrile illness in South India. The clinical features vary from mild illness to severe complications such as gastrointestinal bleed, acute respiratory distress syndrome, meningoencephalitis, and acute kidney injury. The pathological findings are characterized by vasculitis of small vessels of the involved organs. We report probably the first case of scrub typhus-related hemothorax in a 72-year-old diabetic male who presented with acute febrile illness with shortness of breath and acute kidney injury. The patient improved with azithromycin and hemodialysis.

Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.

Impact of focused training on communication skills of final-year medical students in a medical school in India.

BACKGROUND Although communication skills are important for a good physician-patient relationship, Indian medical curricula give very little emphasis on training medical students in this aspect. AIMS To determine the change in communication skills of final-year medical students following focused training. METHODS This was an educational interventional study done at Pondicherry Institute of Medical Sciences, a tertiary care teaching hospital in South India, to assess communication skills among final-year MBBS students. Fifty-two students (24 males and 28 females) participated in the study. A pre-test was conducted in the form of an objectively structured clinical examination (OSCE), followed by focused training for four hours. The same OSCE was administered as post-test. A comparison between the pre-test and post-test scores was done using Wilcoxon Signed Ranks Test. RESULTS Ninety-six per cent of participants (50 out of 52) showed improvement in their performance after the focused training. The mean marks of the pre-test and post-test were 10.77± 3 and 18.04±2, respectively, out of a maximum mark of 20 (p<0.05). One out of 52 participants did not show any improvement, and one participant scored less in the post-test compared to the pre-test. There was no significant difference in the performance between male and female students. CONCLUSION Focused training can enhance the communication skills of medical students. Hence, it may be included in the curriculum of undergraduate medical teaching programmes in India.

Black Coloured Urine following Organophosphorus Poisoning: Report of Two Cases

Organophosphorus poisoning is common in rural Asia. Clinical features result from overactivity of acetylcholine receptors. Blackish discoloration of urine is not a feature of organophosphorus poisoning. Only one case of black colored urine following quinalphos poisoning has been reported in literature. We report two cases of organophosphorus poisoning from two different compounds, following which patients passed black colored urine, in the absence of haemolysis or rhabdomyolysis. These cases indicate that blackish discoloration of urine in organophosphorus poisoning might not be as uncommon as it was believed to be. Besides, urinary excretion of metabolites might be an underlying mechanism, rather than hemolysis.

Miliary tuberculosis with left brachial monoplegia: A case report

Tuberculoma of the brain is a major neurological problem in developing countries accounting for 12 to 30 per cent of all intracranial masses. It often presents with focal neurological symptoms or seizures. Simultaneous occurrence of brain tuberculoma with miliary mottling in the lungs is uncommon in the immunocompetent patient. We report only the second case of monoplegia and miliary tuberculosis, wherein the patient presented with acute onset left brachial monoplegia, upper motor neuron facial palsy, and fever with an MRI of the brain showing multiple granulomas and chest x-ray showing miliary mottling. The patients neurological deficit started to resolve with corticosteroids and anti-tubercular treatment.