Vineet Behera

Rare case of primary cutaneous mucormycosis of the hand caused by Rhizopus microsporus in an immunocompetent patient.

Primary cutaneous mucormycosis is a very uncommon manifestation occurring most often in diabetics or following trauma.

Emphysematous infections of the kidney and urinary tract: a single-center experience.

Emphysematous pyelonephritis (EPN) is a group of potentially life-threatening conditions seen particularly in diabetics, leading to high morbidity and mortality. Our aim was to study the profile of emphysematous infections of the kidney and urinary tract and evaluate the effect of early surgical intervention on mortality. This is an observational study conducted in a tertiary care hospital between January 2009 and January 2013, in which the clinical, laboratory, microbiological and radiological profiles of patients with EPN (diagnosed based on clinical, laboratory and imaging findings) was studied. A total of 12 patients were studied, including 10 with diabetes. A total of 66.6% had pyelonephritis, 25% had both cystitis and pyelonephritis and 8.3% had only cystitis; involvement of the left kidney was more common and bilateral involvement was seen in two cases. The clinical features seen in the patients included fever (100%), features of urinary infection (66.6%) and flank pain (50%). Culture positivity was seen in only 50% of the cases. Ten patients underwent percutaneous drainage (PCD) within 24 h, and two of these patients required nephrectomy subsequently. All patients were followed-up for one month. There was one death (mortality 8.3%), and all other patients responded well and recovered. Our study suggests that EPN is a potentially life-threatening condition that requires aggressive and prompt medical therapy with early PCD to reduce morbidity and mortality. Nephrectomy should be reserved for cases that do not respond to PCD.

Advances in management of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organ systems. In the past 40 years, prognosis for patients with SLE has improved significantly because of advances in the understanding of molecular mechanisms involved in the pathogenesis of disease, which has translated into early diagnosis and novel therapeutic strategies. This article will focus on three aspects that have shaped this transformation, namely; a revisit to diagnostic criteria, development of newer biomarkers, and incorporation of newer targeted therapies.

Osmotic demyelination syndrome in a normonatremic patient of chronic kidney disease

Osmotic Demyelination Syndrome (ODS) is associated with rapid correction of hyponatremia or fluid shifts, and is characterized by neurological involvement related to pons, brainstem or other areas of the brain. All possible measures should be taken to prevent this serious disorder. Diagnosing this condition early is very important and requires a high index of suspicion. The treatment is purely supportive and most patients may show dramatic recovery. ODS occurring in normonatremic and hypernatremic patients is very rare. We report a case of an 18-year-old boy of end-stage renal disease who presented with an episode of acute gastroenteritis. He was managed with aggressive intravenous fluids, hemodialysis and other supportive therapy. But, he developed altered sensorium and seizures that progressed to features of spastic quadriparesis and lower cranial nerve palsy. Neuroimaging showed hyperintensities in pons and midbrain suggestive of ODS. The patient had normal sodium levels at all times and had no evidence of hyponatremia. The patient was managed with hemodialysis, physiotherapy and other conservative measures and had a gradual clinical and radiological recovery.

Severe anaphylactic reaction to diclofenac.

Arachidonic acid metabolism takes place via the cyclo-oxygenase and the lipo-oxygenase pathway. Both the pathways produce potent mediators of a multitude of immune-induced and inflammatory reactions. Any blockade of cyclo-oxygenase pathway (COP) shunts the metabolism towards the lipo-oxygenase pathway (LOP) and can potentially increase the side-effects of that pathway by augmented production and release of cysteinyl-leukotriene.1 Diclofenac is a Non steroidal Anti inflammatory drug with specific inhibiting actions on cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) with relative equipotency. The drug has also been proven to be multimodal in action with extended spectrum of targets including thromboxane-prostanoid receptor, arachidonic acid release and uptake, lipoxygenase enzymes, and activate the nitric oxide-cGMP antinociceptive pathway.2 As the drug has effects on both pathways (COP & LOP), it has been considered safer than other NSAIDs and is extensively used as an analgesic and anti-pyretic in both adults and children. We present a case of a young male who had a severe life threatening anaphylactic reaction to diclofenac.

Kimura disease: A rare case of bilateral infra-auricular masses

A 35 year old male presented to the medicine outpatient department of Armed Forces Medical College, Pune, India, in April 2013, with a painless, progressive and irregular swelling below the both ears since last 10 years with no other systemic symptoms. Clinically, it was firm, non-tender, non-fluctuant swelling about 9x6 cm, located in bilateral infra-auricular areas (Fig. 1). The patient had eosinophilia and elevated IgE levels. His renal parameters and other investigations were normal. MRI showed bilateral lobulated non-homogeneous lesions with moderate contrast enhancement in bilateral parotid region as shown in Fig. 2. Fine needle aspiration cytology (FNAC) was inconclusive and biopsy was suggestive of a subcutaneous swelling with lobulated picture of lymphoid tissue separated by fibrous tissue with significant eosinophilic infiltrate. Fig. 1 (1A - Front view, 1B - Right lateral view, 1C - Left lateral view) shows bilateral infra-auricular swellings due to Kimura disease (arrows) Fig. 2 MRI images (2A - axial section and 2B - transverse section) of the patient showing bilateral infra-auricular enhancing lesions (arrows) Wide excision of swelling was done due to cosmetic indications. Operative findings showed subcutaneous masses which were firm, well defined, located superficial to the parotids with enlargement of intraparotid and other surrounding lymph nodes. The histopathology of the specimen confirmed Kimuras disease. He was continued on cetrizine 10 mg once daily and was closely followed up. After about six months, he had return of swelling initially in the left side followed by the right side possibly due to recurrence of disease which was confirmed by MRI. He was started on oral prednisone 40 mg/day and cyclosporine 200 mg/day which led to regression of swelling. Presently, the swelling has subsided and the patient is on maintenance of prednisone 5 mg on alternate days and cyclosporine.

Megaloblastic Anemia Presenting with Massive Reversible Splenomegaly

Megaloblastic anemia (MA) is a common disorder with varied manifestations. It generally results in mild to moderate splenomegaly which is due to sequestration of macrocytic erythrocytes in spleen. Massive splenomegaly is generally seen in infections, myeloproliferative diseases, neoplasms, storage disorders or hematological conditions; but is not heard of and has rarely been reported in MA. We discuss a case of massive splenomegaly who presented with symptomatic anemia and was found to have MA. He was extensive evaluated for all other causes of massive splenomegaly which was normal. Further, after a therapeutic trial of MA he showed a regression in spleen size confirming that the massive splenomegaly was attributable to MA.

Antiretroviral therapy-induced lipodystrophy.

A 55-year-old man was detected with pulmonary tuberculosis 5 years earlier and was also detected to be HIV positive with a CD4 count of 362/mm3. A course of antitubercular therapy (oral isoniazid 300 mg once daily, rifampicin 600 mg once daily, ethambutol 1000 mg once daily and pyrazinamide 1500 mg once daily) was given for 6 months and the patient was cured of tuberculosis. The patient was started on antiretroviral therapy (ART) comprising of zidovudine, lamivudine and nevirapine. Over the next 2 years, the course was uneventful but there was progressive decline in CD4 count and increase in HIV viral load. In …

Duchenne muscular dystrophy.

A 15-year-old boy presented with progressive proximal weakness of the lower limbs starting at 4 years of age followed by involvement of the upper limbs. He is the product of a consanguineous marriage; he had a family history of similar disease in a second-degree cousin and also had a history of delayed motor developmental milestones since birth. Clinically, he had flaccid …