Wasim Md Mohosinul Haque

Emphysematous Pyelonephritis: Experience of Managing 15 Consecutive Cases in a Tertiary Care Hospital of Bangladesh

Background: Carpal tunnel syndrome (CTS) is one of the most frequent entrapment neuropathies of the upper limb. CTS and diabetic polyneuropathy (DPN) are common conditions in patients with diabetes and therefore frequently occur concomitantly. Diagnosis of CTS in patients with DPN is important, as therapeutic interventions directed toward relief of CTS may be effective irrespective of diffuse neuropathy. Methods: This study was a hospital based descriptive cross sectional study done in a tertiary care hospital, Dhaka between July, 2015 and June, 2016. The initial clinical diagnosis of diabetic peripheral neuropathy was made from history and examination. It was confirmed by doing nerve conduction study. After having informed written consents, a standard preformed questionnaire was filled up for each case. Collected data were checked, verified for consistency and edited for final results. Data cleaning, validation and analysis were performed using Statistical Package for the Social Sciences (Version 20.0). Results: A total of 354 cases were finally analyzed with 153 (43.2) patients being symptomatic for CTS and among those 54 (58.7%) had electrophysiology proven CTS. It was observed that 26.0% of patients established as having DPN also had CTS. The frequency of CTS among those with symptoms was significantly higher than in asymptomatic participants. The mean age was found to be 55.99 ± 9.25 years with a range from 28 to 80 years. Majority (38.4%) of patients belonged to the age group of 51-60 years. Among all cases of electrophysiology proven CTS (92 patients), females (53.3%) numbered greater in comparison to males (46.7%). One hundred and ninety two (54.2%) patients were housewives, 57 (16.1%) were garment workers, 45 (12.7%) patients were businessmen and 60 (16.9%) patients were service holders. Study subjects with CTS had significantly higher body mass index, higher fasting blood glucose and higher HemoglobinA1c in comparison to patients without CTS. Examination of upper limb sensory nerves showed that nerve conduction velocity was significantly decreased and distal latency was found to be significantly increased in patients with CTS on median nerve examination. The mean compound motor action potential was not significantly different between patients with and without CTS. Conclusion: Symptoms and signs of CTS are mostly masked by the symptoms of DPN and patients presenting with such symptoms in the upper limbs should be evaluated for CTS as a separate entity to DPN. The finding of a frequency of CTS of 26% in subjects with diabetes with varying degrees of DPN is remarkably high. Given the high prevalence of CTS in subjects with DPN, it is recommended that therapeutic decisions be made carefully after nerve conduction study and proper diagnosis. Birdem Med J 2018; 8(3): 246-250

Community Acquired Acute Kidney Injury from Edible Agents: Report from a Developing Country, Bangladesh

Toxin is a common cause of community acquired acute kidney injury (AKI) which includes environmental toxins like plant toxins as well as various drugs and chemicals which are usually ingested for medicinal as well as recreational purposes. Averrhoa carambola (Star fruit/ Kamranga) and Avorrhoa bilimbi are two such commonly used traditional remedies. They belong to family Oxalidaecae and contain high-levels of oxalic acid. AKI may occur after consuming concentrated juice due to deposition of oxalate crystals in the renal tubules. Here we present two patients who developed AKI after ingestion of freshly made juice from A. bilimbi and star fruit. Both patients were diabetic and the juice was ingested on empty stomach with the belief of improving glycemic status. Initial presentation was GI upset in both scenarios. Patient with A. bilimbi toxicity had diabetic nephropathy and required hemodialysis. Renal biopsy revealed deposition of polarizable oxalate crystals in the patient who consumed A. bilimbi and acute tubular necrosis in the patient with star fruit toxicity. All cases regained normal renal function within three months. We also present a patient who ingested raw fish gallbladder as a remedy for asthma. The patient presented with AKI within five days of ingestion and required hemodialysis. His highest serum creatinine was 10.4mg/dl and fell to 1.7 mg/dl after four weeks. Cyprinol and related compounds in fish gallbladder are thought to be the cause of acute tubular necrosis in such cases. The fourth patient developed AKI with rhabdomyolysis after consuming a locally made energy drink. He also required dialysis and serum creatinine gradually improved from 7.2mg/dl to 1.4mg/dl at discharge. The possibility of toxicity of caffeine, adulteration with other chemicals or ascorbic acid toxicity causing oxalate nephropathy could not be excluded. All four patients developed AKI caused after ingesting easily available products and are presented here for public awareness. We believe proper knowledge and education can reduce toxin induced AKI in our society.

Haemophagocytic syndrome in an adult suffering from pyrexia of unknown origin: an uncommon presentation of tuberculosis: a case report

BackgroundTuberculosis is common, can involve various organs of the body and may have diverse presentations. Haemophagocytic syndrome is one of the rare presentations of tuberculosis carrying a very high mortality. Early detection and institution of anti-tuberculosis medications can be life-saving.Case presentationA 23-year-old Bengali man presented with prolonged fever, weight loss, hepatosplenomegaly, pancytopenia and altered liver function. He had high erythrocyte sedimentation rate, positive tuberculin test, granuloma in liver biopsy, and haemophagocytosis was evidenced by histopathological examination of bone marrow. He recovered with anti-tuberculosis therapy.ConclusionThis case demonstrates that consideration of tuberculosis as an underlying cause of haemophagocytic syndrome could be rewarding and life-saving in this rapidly fatal condition.

Serum Intact Parathyroid Hormone Level is Inversely Correlated with Glycated Haemoglobin in Diabetic Chronic Kidney Disease Stages 3-5 Predialysis Patients

Introduction: Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD). Management of chronic kidney disease-mineral and bone disorder (CKD-MBD) is an integral component of CKD management; serum intact parathyroid hormone (iPTH) level is the key target. This study was designed to evaluate the relationship between glycated haemoglobin (HbAlc) and iPTH in diabetic CKD stages 3-5 patients not yet on dialysis. Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from CKD stages 3-5, who were not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including HbAlc and iPTH levels were recorded for all patients. Data were analyzed by using SPSS version 20.0 and Pearson’s correlation test was applied to evaluate the relationship between HbAlc and iPTH. Results: Total patients were 306, including 166 (54.2%) males. Mean age was 56.5±11.3 years. Mean duration of DM and CKD were 12.8±7.6 and 2.9±1.7 years respectively. Among the study population, 49 (16.0%) were in CKD stage 3, 90 (29.4%) in CKD stage 4 and rest 167 (54.6%) in CKD stage 5. Mean HbAlc (%), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), alkaline phosphatase (U/L) and iPTH (pg/ml) were 7.77±2.14, 6.8±3.0, 141.1±75.7, 8.1±1.2, 5.2±1.9,164.1±135.3 and 229.7±151.2 respectively. Mean HbAlc (%) and iPTH (pg/ml) in CKD stages 3, 4 and 5 were 8.36±1.59 and 171.7±127.9, 7.99±1.92 and 179.5±131.4, and 7.77±2.14 and 273.8±119.2 respectively. On correlation analysis, HbAlc had a significant negative correlation with iPTH (r=-0.002). Conclusion: The results of current study showed that most diabetic CKD stages 3-5 predialysis patients had poor glycaemic control and HbAlc had negative correlation with iPTH. As iPTH level is influenced by presence and control of DM, the targets of iPTH in CKD stages 3-5 in general, as recommended in existing guidelines, may not be appropriate in diabetic CKD patients and this issue merits further investigation. Birdem Med J 2017; 7(2): 110-113

Outcome of Acute Kidney Injury in Patients with Type 2 Diabetes Mellitus

Background: Diabetic patients are more vulnerable to develop acute kidney injury (AKI) when compared to non diabetic counterpart. However, it is not known whether outcome of AKI is variable according to etiology in diabetic subjects. This study was aimed to observe the causes of AKI in diabetic population and to evaluate the outcome. Methods: This cross-sectional study was done in Department of Nephrology, BIRDEM General Hospital, from May 2009 to April 2010. During the study period a total of 50 subjects were included. All cases of AKI and AKI on chronic kidney disease (CKD) were included except AKI due to trauma. Results: AKI due to acute gastroenteritis, non-steroidal anti-inflammatory drugs (NSAIDs),septicemia, gentamicin, obstructive uropathy, rapidly progressive glomerulonephritis (RPGN) comprised 46%, 42%, 4%, 2%,2%, and 4% cases respectively. All cases of AKI due to acute gastroenteritis improved. Among NSAID induced AKI, 26% improved, 6% improved with residual renal damage, 8% did not improve and 1% patient expired. All cases of septicemia induced AKI improved. Patient with gentamicin induced AKI improved with residual renal damage. Patient with obstructive uropathy improved. None of AKI cases due to RPGN improved. Conclusion: It may be suggested that outcome of AKI is variable according to etiology. Outcome is better in AKI due to pre-renal and post-renal causes than AKI due to intrinsic causes. Further study can be done to compare the outcome of AKI according to etiology between diabetic and non-diabetic populations. Birdem Med J 2016; 6(2): 95-99

Basiliximab as Induction in Kidney Transplantation: Are There any Real-Life Advantages?

Background: Basiliximab is an interleukin-2 receptor antagonist used as induction therapy in kidney transplantation and is believed to reduce acute rejection episode (ARE). Our aims were to compare the impact of basiliximab induction therapy with no induction therapy on incidence of ARE, time requirement for serum creatinine (S.Cr) to normalize after transplantation, initial post-transplant hospital stay, infection in immediate post-transplant period, chronic allograft injury and graft survival at 1 and 3 years. Methods: We retrospectively reviewed the medical records of patients who had undergone living related donor kidney transplantation in a tertiary care hospital of a developing country between July 2004 and June 2014. We selected patients who received calcineurin inhibitors, mycophenolate and prednisolone to classify as no induction therapy (n=50; group 1, receiving prednisolone, mycophenolate and cyclosporine as maintenance therapy) and induction therapy with basiliximab (n=61; group 2, receiving prednisolone, mycophenolate and tacrolimus as maintenance therapy). Results: Among the 111 study subjects, only two had experienced ARE (one from each group, p=0.889). Patients who received basiliximab had a shorter mean hospital stay (11.4±3.3 versus 13.7±5.0 days, p=0.005) and shorter mean duration for normalization of S.Cr (4.7±2.3 versus 7.3±5.6 days, p=0.002) after transplantation. There was no significant difference in incidence of infection in immediate post-transplant period (p=0.134). One year graft survival rate was better in those who received basiliximab (98.2% versus 89.4%, p=0.010) but there was no significant difference at 3 years (79% versus 74%, p=0.549). Overall incidence of chronic allograft injury was less with basiliximab (11.5% versus 36%, p=0.002) induction. Conclusions: Induction therapy with basiliximab was associated with shorter mean hospital stay, early renal function recovery, better 1 year graft survival and less overall incidence of chronic allograft injury. We have encountered minimum ARE to comment on benefit of basiliximab on ARE. Birdem Med J 2017; 7(2): 90-94

A Two Year Observation on Trend of Primary Glomerulonephritis in A Tertiary Care Hospital of Bangladesh

Aim: Glomerulonephritis remains the most probable underlying cause of end stage renal disease of uncertain aetiology in many developing countries, including Bangladesh. The pattern of glomerular disease varies widely from country to country. In Bangladesh, the incidence and histological pattern of glomerulonephritis is inadequately described. We performed a study, aiming to determine pattern of primary glomerulonephritis in a tertiary care hospital of our country. Material & Methods: It was a cross-sectional hospital based prospective study conducted at BIRDEM general hospital starting from from July 2013 to June 2015. It included all patients with primary glomerulonephritis and who underwent native kidney biopsy. Result: Total 67 biopsy were performed and among them primary glomerulonephritis was 42. Female and male ratio was 1.3:1 and mean age was 42.73±14 (14-75) years. Indications of biopsy were proteinuria (>1gm/day) and unexplained acute kidney injury. The commonest histopathological pattern in primary glomerulonephritis was membranoproliferative glomerulonephritis 33.33% (14/ 42) followed by mesangial proliferative glomerulonephritis 30.95% (13/42). Only three (7%) patient required blood transfusion for post biopsy bleeding. No one required nephrectomy. Conclusion: In conclusion, mesangial proliferative and membranoproliferative glomerulonephritis are the two most common causes of primary glomerulonephritis. Nephrotic range proteinuria was the main indication of biopsy. Post biopsy complication was negligible. Creation of a national renal registry is essential for obtaining more specific epidemiological data. Bangladesh J Medicine Jul 2016; 27(2) : 68-70