Virendra Atam

Association of carotid plaque echogenicity with recurrence of ischemic stroke.

Background: Atherosclerosis is related to various cardiovascular and cerebrovascular events like cerebral infarction. Recurrence of ischemic stroke is specifically related to atherosclerotic load as determined by the presence of carotid atheromatous plaques and its echogenicity. Aim: This study was to evaluate the association of recurrence of stroke with echogenic characteristics of carotid plaque in ischemic stroke patients. Materials and Methods: Carotid sonography using high-resolution 7.5 MHz along with gray-scale technique was done in each ischemic stroke patient to find the occurrence of plaque and its echogenicity according to Mannheim Carotid Intima-Media Thickness Consensus (2004-2006). Followup of patient done to know the recurrence of stroke during 6-month duration and its association with plaque echogenicity. Results: A significant association found between the presence of plaque and known cerebrovascular risk factors. Also significant association found between recurrence of stroke and echolucent character of carotid plaque in bivariate analysis (P = 0.0028). Conclusions: Recurrence of stroke is related to advanced stage of atherosclerosis that is specified by carotid plaque and its characteristics. It will help us to identify groups of patients at different risk for stroke and planning better strategies to prevent such events.

Clinical Profile of Neurological Manifestation in Human Immunodeficiency Virus-positive Patients.

Human Immunodeficiency Virus (HIV) infection is a global pandemic. According to the data released by UNAIDS in 2007, India had 2.5 million people living with HIV infection.[1] Next to sub-Saharan Africa, it has the second largest burden of HIV-related illness. Though the main targets of HIV infection are the cells of the immune system, the nervous system is often damaged during the course of infection, not only by disease processes that are secondary to immune dysfunction but also by more fundamental effects of the retrovirus.

Role of erythrocyte sedimentation rate in ischemic stroke as an inflammatory marker of carotid atherosclerosis

Background: Inflammation mediates a key role in the pathogenesis of atherosclerosis which is an important cause of ischemic stroke. An elevated erythrocyte sedimentation rate (ESR) may, therefore, be a marker of the extent andor intensity of a general atherosclerotic process and thus a marker for advanced atherosclerosis heralding increased risk of arterial thrombosis leading to ischemic stroke. Materials and Methods: ESR was calculated in ischemic stroke patients by Westergrens method along with carotid sonography using high resolution 7.5 MHz techniques to find the prevalence of increased carotid intima-media thickness (CIMT) and presence of plaque according to Mannheim Carotid Intima-Media Thickness Consensus. Results: Average value of ESR in all patients was 27.89 ± 9.73 mm/h. A significant association was found between ESR and markers of carotid atherosclerosis, that is, high CIMT of more than 0.8 mm (P < 0.0001) and presence of plaque (P-0.026) in univariate analysis. Also, a significant positive correlation was found between ESR and serum fibrinogen, another inflammatory marker. (r = 0.88, P < 0.0001). Conclusion: The extent of inflammation may reflect in part the propensity of atherosclerotic lesions to lead to clinical disease. Study shows the association of ESR with markers of atherosclerosis confirming the strength of the inflammatory response associated with carotid atherosclerosis and might conceivably carry important prognostic information regarding occurrence of such catastrophic events in future.

The etiological diagnosis and outcome in patients of acute febrile encephalopathy: A prospective observational study at tertiary care center

BACKGROUND Acute febrile encephalopathy (AFE) is a clinical term used to an altered mental state that either accompanies or follows a short febrile illness and is characterized by a diffuse and nonspecific brain insult manifested by a combination of coma, seizures, and decerebration. OBJECTIVE To identify the etiological diagnosis and outcome in adult patients with AFE. SETTINGS AND DESIGN A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care center in northwest India. MATERIALS AND METHODS The non-infectious causes of unconsciousness were excluded and then only a diagnosis of AFE was considered. Cerebrospinal fluid (CSF) analysis and imaging of brain was done to determine the possible etiology. Outcome was assessed at 1 month of follow-up after discharge by using modified Rankin Scale (mRS). Data were analyzed and presented as mean, median, and percentages. A P value of <0.05 was considered significant. RESULTS Of the total 120 patients studied, pyogenic meningitis was the most common cause accounting for 36.7%, followed by acute viral encephalitis (AVE) in 28.33% of the patients (Japanese B encephalitis in 12.5%, herpes simplex virus encephalitis in 3.33%, and other undetermined viral etiology in 12.5%). Cerebral malaria, sepsis associated encephalopathy (SAE), and tuberculous meningitis were diagnosed in 21.7%, 9.17%, and 4.2% of cases, respectively. Of the total, 16 patients died, 6 with AVE, 3 with pyogenic meningitis, 3 with cerebral malaria, and 4 with SAE. mRS at discharge was >3 in 14 patients with AVE (P < 0.001), and in the remaining it was <3. After 1 month, mRS was >3 in six patients with AVE and in the rest it was ≤1 (P < 0.001). CONCLUSIONS In this study, pyogenic meningitis was the leading cause of AFE, followed by AVE and cerebral malaria. The outcome in cases with AVE can be fatal or more disabling than other etiologies.

Prognostic Significance of Estimation of Pseudocholinesterase Activity and Role of Pralidoxime Therapy in Organophosphorous Poisoning

Background: Organophosphorous (OP) poisoning is one of the most common poisonings seen in India. OP compounds act through inhibition of enzyme acetylcholinesterase and estimation of pseudocholinesterase (PCE) activity strengthens the diagnosis in clinically uncertain cases of OP poisoning. The role of pralidoxime (PAM) therapy in OP poisoning has been controversial. Study Objectives: This study was aimed to determine the prognostic significance of estimation of PCE activity and also to assess the role of PAM therapy in OP poisoning. Materials and Methods: Patients of suspected OP poisoning of age >12 years admitted to emergency unit at a tertiary healthcare center of north India were enrolled. Patients were categorized into two groups; group A who were given intravenous atropine and group B who were given injectable PAM along with atropine. Serum PCE level was estimated at the time of admission in all patients and severity of OP poisoning was assessed according to PCE level. Requirement of atropine, oxygen inhalation, intubation and ventilatory support, total hospital stay, and mortality were compared between different classes of severity and also between Groups A and B. Results: This study included a total of 70 subjects, 35 in each group with mean age of 24.99 ± 8.7 years. Out of 70 subjects 49 (70%) were male and 21 (30%) were female. Forty nine patients (70%) of OP poisoning were with suicidal intent while 21 (30%) cases were accidentally poisoned. In all suicidal cases route of poisoning was ingestion whereas in all the accidental cases route of exposure was inhalational. PCE levels were reduced in all the cases and the mean level was 3,154.16 ± 2,562.40 IU/L. The total dose of atropine required, need for oxygen inhalation and need for intubation and ventilatory support, mean duration of hospital stay and mortality rate (P = 0.003) were higher in moderate to severe cases and did not have significant difference between Groups A and B. Conclusion: The study recommends estimation of PCE level at admission to classify severity of OP poisoning and to estimate prognosis. This study did not find any beneficial role of PAM therapy in reducing morbidity as well as mortality.

Relation of glycated hemoglobin with carotid atherosclerosis in ischemic stroke patients: An observational study in Indian population

Context: Glycated hemoglobin A1c(HbA1c) indicates long-term uncontrolled hyperglycemia in the body, which in diabetic patients leads to various vascular complications as a part of generalized atherosclerosis culminating ultimately into ischemic stroke. Aims: Study aims to show the association between marker of uncontrolled long-term hyperglycemia HbA1c and marker of atherosclerosis (Carotid intima media thickness [CIMT] and carotid plaque) in ischemic stroke patients. Subjects and Methods: Carotid sonography using high resolution 7.5 MHz sonography technique was done in each patient to find the occurrence of increased CIMT and presence of plaque according to Mannheim CIMT Consensus (2004-2006). Levels of HbA1c measured in blood in both diabetic and non-diabetic patients and a comparison made between them. Finally an association sought between HbA1c levels with CIMT and plaque. Results: The average value of HbA1c of this cohort was 7.51 ± 1.75% with higher values in diabetic patients (9.29 ± 1.73%). The patients with high CIMT (>0.8 mm) had higher values of HbA1c then that of normal CIMT patients and this was nearly significantly (P = 0.06). However, HbA1c levels of blood were significantly associated with stroke patients with presence of carotid arteries plaque (P = 0.008). Conclusions: Prediction of future risk and prevention strategies for ischemic stroke could be formulated by utilizing HbA1c levels in both diabetic and non-diabetic population.

Drug reaction with eosinophilia and systemic symptoms syndrome associated with Nitrofurantoin

Drug reaction with eosinophilia and systemic symptom (DRESS) is a severe adverse drug-induced reaction with a prolonged latency period which is characterized by a variety of clinical manifestations, usually fever, rash, lymphadenopathy, eosinophilia, and a wide range of mild-to-severe systemic presentations. Drugs are an important cause of DRESS in most of the cases. It is challenging to diagnose DRESS because of the diversity of cutaneous eruption and visceral organs involvement. We hereby report a 34-year-old female who developed DRESS syndrome following ingestion of nitrofurantoin for the treatment of urinary tract infection. She was managed conservatively and recovered after few weeks. Our aim of this study is to raise awareness to suspect DRESS syndrome in patients who present with unusual clinical features with skin involvement after initiating any drug.

Effect of CPAP Therapy in Improving Daytime Sleepiness in Indian Patients with Moderate and Severe OSA

INTRODUCTION Obstructive Sleep Apnoea (OSA) is a highly prevalent disease and a major public health issue in India. Excessive daytime sleepiness is an almost ubiquitous symptom of OSA. Epworth Sleepiness Scale (ESS) score is a validated objective score to measure the degree of daytime sleepiness. Continuous Positive Airway Pressure (CPAP) therapy has been established as the gold standard treatment modality for OSA patients. A few Indian studies have reported the effectiveness of CPAP therapy in improving ESS scores after 1st month of CPAP use. AIM To observe both, short-term (one month) and long-term (three month) effects of CPAP therapy on ESS scores in moderate to severe OSA patients. MATERIALS AND METHODS The patients complaining of excessive day-time sleepiness, snoring and choking episodes during sleep, consecutively presenting to medicine OPD over a period of 2 years, were subjected to Polysomnography (PSG). Seventy-three patients with apnoea-hypopnea index (AHI) ≥15 were categorised as having moderate to severe forms of OSA (moderate OSA with AHI=15-30 and severe OSA with AHI >30), and were scheduled for an initial trial of CPAP therapy. Forty-seven patients reported good tolerance to CPAP therapy after a trial period of 2 weeks and comprised the final study group. ESS scores in these patients were recorded at the baseline, and after 1st and 3rd month of CPAP therapy, and statistically analysed for significance. RESULTS Mean ESS score at the baseline among moderate and severe OSA patients were 13.67±2.29 and 16.56 ±1.87, respectively. ESS score in both these subgroups improved significantly to 11.63±3.79, p=0.022, CI (0.3293-4.0106)} and 14.13 ±3.74, p < 0.001, CI (1.2991-4.5408), respectively after one month of CPAP therapy. Likewise, mean ESS scores among moderate and severe OSA patients improved significantly to 9.84 ±2.97, p = 0.022, CI (0.3293-4.0106) and 12.29 ±3.97, p <0.001, CI (2.9414-6.1385), respectively after three months of CPAP therapy. CONCLUSION The result of the present study shows that CPAP therapy is significantly effective in improving ESS scores in Indian patients having moderate to severe OSA. Benefits in daytime sleepiness were observed after short-term as well as long-term use of CPAP therapy.

Non Neurological Manifestations in Acute Encephalitis Syndrome in Uttar Pradesh, India

Non neurological features of Acute Encephalitis Syndrome (AES) or of Japanese Encephalitis (JE) have been scarcely reported. Objective: To study hematological, hepatic and renal manifestations in patients of JE and compare with non JE. Methods: Patients of AES admitted to hospital were screened for enrolment and testing for anti JEV IgM following inclusion and exclusion criteria. Enrolled patients were subjected to detailed history, physical examination and investigation according to a predesigned proforma. Cerebrospinal fluid or serum collected at admission was subjected to ELISA test for anti JEV IgM. If this was negative, a repeat test was done in serum after 7-10 days. Patients positive for IgM in CSF or serum were considered JE positive. Those negative for IgM when tested after one week of illness were considered non JE. Clinical and laboratory non neurological features were compared between JE and non JE. Results: A total of 456 AES patients were enrolled and tested for JEV IgM, of which 224 were non JE and 110 were JE. Abnormal platelets and liver and renal function were found in both groups. Non JE AES patients were significantly more likely to have splenomegaly and lower platelet counts, but higher hepatic transaminases and International Normalized Ratio (INR). Conclusions: Non neurological manifestations are common in both JE and non JE AES seen here and are more frequent in non JE.

Various neurological manifestations in HIV positive patients, their outcome and its correlation with CD 4 counts- A tertiary centre experience in North Indian population

The central nervous system (CNS) is among the most frequent and main target of HIV infection in severely immunocompromised patients. Neurological m anifestations occur due to either primary pathologic process of HIV or secondary to opportuni stic infection. The present study was conducted to ascertain the prevalence of various neurological ma nifestations in HIV positive patients, correlation of CD4 levels in CNS opportunistic infection and their ou tcome. This was a prospective observational study of 105 HIV infected patients with clinical ev idence of CNS involvement. A detailed clinical hist ory and CNS examination was carried out. CD 4 counts was measured by flow cytometry method and o ther investigations like magnetic resonance imaging (MRI ), brain/electromyography, nerve conduction studies and cerebrospinal fluid (CSF) examination w ere done as required for diagnosis. HIV induced primary illness was present in about 30% cases whil e 70% associated with secondary CNS manifestations were mainly due to opportunistic inf ection. The most common primary illness was distal symmetrical polyneuropathy (20.9%), followed by AID S dementia complex (3.8%), acute inflammatory demyelinating neuropathy (3.8%). On the other hand, the most common secondary CNS infection was tuberculous bacterial (TBM; 32.3%), followed by cry ptococcal meningitis (13.3%), progressive multifoca l leukoencephalopathy (PML; 11.4%), and cerebral toxo plasmosis (9.5%). The commonest presenting symptoms of TBM were fever (72.38%), while headache and vomiting was 27.62 and 28.57%, respectively. Mean CD 4 count was 172 ± 81.2 in distal symmetrical polyneu ropathy (DSPN), 282 ± 75.3 in acute inflammatory demyelinating neuropathy (AIDP) and 95 ± 6.5 for AIDS dementia complex.