Journal of clinical and diagnostic research

Detection of NDM-1 in Clinical Isolates of Klebsiella Pneumoniae from Northeast India

Arijit Bora, Giasuddin Ahmed,

Introduction: The growing incidence of the resistance to carbapenems among the members of Enterobacteriaceae is of major concern throughout the world, as these drugs are often used now-a-days as the last line of effective treatment against the serious infections which are caused by multidrug resistant Enterobacteriaceae. We detected blaNDM-1 in the Klebsiella pneumoniae isolates which were collected from a tertiary care referral hospital in northeast India. Materials and Methods: A total of 219 non-duplicated K. pneumoniae isolates were recovered from various clinical samples between August 2009 and July 2010. These isolates were screened for the detection of carbapenemase production on the basis of their reduced susceptibility to meropenem or ertapenem by the disc diffusion method. The screened isolates were further phenotypically studied for carbapenemase production by the modified Hodge test and the detection of metallo-β-lactamase production was carried out by using the combined disc test. All the screened isolates were also subjected to PCR detection of the blaNDM-1 gene and the additional bla genes which coded for TEM, SHV, CTX-M, and AmpC. Results: Out of the 219 isolates, 19 were screened for the detection of carbapenemase production on the basis of their reduced susceptibility to meropenem or ertapenem. Both the phenotypic confirmatory tests showed positive results for all the screening positive isolates, although few weakly positive reactions for the modified Hodge test were observed. All the screened isolates were found to be positive for blaNDM-1. Each of the blaNDM-1 possessing isolates was also found to be positive for one or more additional bla genes. Conclusion: This study indicated that the incidence of blaNDM-1, together with that of one or more additional bla genes among the K. pneumoniae isolates from hospitalized and non hospitalized patients in northeast India.

Evaluation of Sonicated and Heat Extracted Lipopolysaccharide Brucella Abortus Antigens by an In House Enzyme Linked Immunosorbant Assay

Supriya Christopher, B.L. Umapathy, K.L. Ravikumar

Aim: Brucellae are small gram negative coccobacilli that are known to cause brucellosis, the most common zoonotic disease world wide. The multisystem involvement and the protean and the unusual clinical presentation of the disease pose significant diagnostic challenges. Although the isolation of the causative organism is the definitive proof of the disease aetiology, practical difficulties are encountered. Hence, serological tests remain the most commonly used methods for its laboratory diagnosis. The standard tube agglutination test (STT) is the conventional serological test which is used. Method: The present study was carried out to evaluate the two different antigenic preparations from the smooth stains of B. abortus S99 for standardizing the enzyme linked immunosorbant assay (ELISA) as an alternative for STT. The standard tube agglutination test antigen and the standard antibrucella serum which were obtained from IVRI, Izathnagar, were used as the controls for the standardization of the ELISA. A sonicated lipopolysaccharide antigen (LPS-SE) and a heat extracted lipopolysaccharide antigen (LPS-HE) were evaluated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and they were used to coat the micro titre plates for the enzyme linked immunosorbant assay. 81 human sera from people who were working in organized farms (cases), hundred human sera from apparently healthy persons (controls) and 100 Widal positive samples were selected to check for the crossreactivity for this study. All the serum samples (the cases , controls and the WIDAL positive samples ) were tested by the standard tube agglutination test (STT).This study was conducted over a period of four years at a tertiary care hospital in India. Results: Among the 81 cases, eight (9.87%) sera gave a titre of ≥ 1:80 by STT, whereas by ELISA, 10(12.34%) and 9 (11.11%) cases showed significant titres on the LPS-SE and the LPS-HE coated plates respectively. The accuracy of the ELISA by using both LPS-SE and LPS –HE was 93.83% and 95.86%, with a p value of > 0.001, as compared to STT. Conclusion: The overall seroprevalence with ELISA was 12.34% and 11.11% with the LPS-SE and the LPS-HE antigens, whereas it was 9.87% with STT. Hence, ELISA can be considered as a better diagnostic serological test for the diagnosis of brucellosis. It is cheap and reproducible and the antigen coated plates can be stored for longer periods.

Acinetobacter spp.: An Emerging Pathogen in Neonatal Septicaemia

ABSTRACT Background and objectives: Acinetobacter spp. are gaining importance as a potential pathogen in neonatal septicaemia because of its frequent isolation and multidrug resistance. The aim of the present study is to investigate the incidence of Acinetobacter septicaemia in neonates and its antibiotic resistance pattern. Materials and Methods: Neonates admitted to the neonatal intensive care unit with signs suggestive of sepsis were recruited into this prospective study.Blood culture and Antibiotic sensitivity test were carried out. Results: Out of 50, 14 were blood culture positive, Acinetobacter accounted for 5 (35.7%) of the blood culture positive sepsis. Other organisms were Citrobacter koseri(7.14%) Klebsiella oxytoca(7.14%), Staphylococcus aureus(14.29%), Klebsiella pneumoniae (21.42%), Pseudomonas aeruginosa (7.14%), Coagulase negative Staphylococci(7.14%).The organism was sensitive to Ampicillin (20%), Ciprofloxacin (40%), Amikacin (40%),Gentamicin(60),Doxycycline(20%),Cefotaxime(60%),Meropenem(100%),Imipenem(100%),Piperacillin+Tazobactam (100%). Conclusions: Low birth weight and preterm delivery are the potential risk factors of Acinetobacter sepsis. Sensitivity of Acinetobacter has changed over the years, previously they are sensitive to cephalosporins but now they have become resistant to it.High incidence of sepsis in institutional delivery indicates that the theatre protocol should be maintained.28% of cases were only culture positive ,remaining clinical sepsis cases must be investigated for anaerobic infection.To prevent acinetobacter

Wristwatches as the Potential Sources of Hospital-Acquired Infections

ABSTRACT Background: Nosocomial pathogens can survive on inanimate surfaces for long periods of time. Therefore, the personal items which are used by HCWs such as mobile phones, wristwatches and pens can be continuous sources for the transmission of infections in the absence of regular surface disinfection practices. Aims: The aim of the study was to measure the rate of bacterial hand and wrist contamination, particularly that which was caused by Staphylococcus aureus, amongst healthcare workers (HCWs) who wore wristwatches. Methods and Materials: The wrists and the hands of hospital-based healthcare workers (HCWs) were sampled for bacterial contamination in two consecutive, cross-sectional cohort studies of wristwatch wearers and non-wristwatch wearers. In the first study, the wrists were sampled by using skin swabs and the hands were sampled by direct plate inoculation. In the second study, the wrists were sampled after each HCW removed the watch immediately prior to the sampling. Results: Staphylococcus aureus was found on the hands of 64% wristwatch wearers and 36% non-wristwatch wearers in the first study. The watch wearers had higher counts of bacteria on their wrists than on their hands. In the second study, the removal of the watch prior to the sampling resulted in increased counts of bacteria on both the hands as well as on the watch wrist as compared to that in the non-watch wearers. Wearing a wristwatch results in an increase in the bacterial contamination on the wrist, but excess hand contamination does not occur unless the watch is manipulated. Conclusions: Wearing a wristwatch results in an increase in the bacterial contamination on the wrist, but excess hand contamination does not occur unless the watch is manipulated.This study emphasizes the importance of increased hand hygiene compliance and the surface disinfection of the personal items which are used by the HCWs. The regular surface disinfection of these items and also regular hand washing can contribute to a reduction in the transmission of nosocomial pathogens in the health care setting.

The Bilateral Sternalis: An Uncommon Anatomical Variant

In the present era of the medical practice, an increased alertness for a thorough knowledge of the anatomical variants with a clinical significance has been recorded, in order to minimize the risks of misdiagnosis and the surgical complications thereof. We are reporting a series of 50 cadaveric dissections of the pectoral region with a 2% incidence of the sternalis muscle. The existence of the sternalis muscle and its location, orientation and early identification are necessary in breast surgeries. So also in the imaging of the chest wall by CT and MRI and the mammographic evaluation of breast lesions.

Methicillin resistant Staphylococcus aureus Carriage among the Health Care Workers in a Tertiary Care Hospital

Background: Methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infection outbreaks and prevalence among various populations have been well reported in the literature, particularly with respect to the developed and the developing countries. The hospital personnel tend to have higher colonization of MRSA than the general population. The personnel with MRSA colonization are the sources of dissemination of the organisms, both in the hospital and the community. Aim: The present study was conducted to assess the carriage rate of MRSA among health care workers (HCWs). Design: A hospital based prospective study. Place and Duration: Department of Microbiology, ESIC-MC-PGIMSR, Rajajinagar, Bangalore, from October 2010 to April 2011. Materials and Methods: A total of 150 HCWs who were involved in the management of critically ill patients [in the intensive care unit (adult), all surgical specialties, post-operative surgical wards, major OT and minor OT] were screened for MRSA by collecting their nasal swabs, throat swabs and swabs from the webs of their fingers. Staphylococcus aureus was identified by the standard methods. Antibiotic susceptibility was performed according to the Kirby-Bauer disc diffusion method. MRSA was identified by using a cefoxitin 30 mcg disc and it was interpreted according to the Clinical Laboratory Standards Institute guidelines. All the carriers which were identified were decolonized with Mupirocin (Supirocin ointment 2% Glen mark), local application twice a day for ten days, and subsequently, they were checked for the decolonized state. Statistical analysis: The findings were statistically analyzed by using the Chi-square test. Results: Of the 150 HCWs who were screened, 15 (10%) had MRSA either in the nose or on the hand. The nasal carriage of MRSA was higher (8%) than the hand carriage (2%) and none had throat carriage as compared to the Methicillin sensitive Staphylococcus aureus carriage rate in the nose and on the hand 3.4% and 0.6% respectively, which was statistically significant (p< 0.05). Doctors, nurses and nursing orderlies were the predominant carriers (4%, 2%, and 2%, respectively). The antibiogram of the MRSA isolates revealed the highest resistance to penicillin and amoxyclav (93% each). The sensitivity to erythromycin, gentamicin, amikacin, ciprofloxacin and cotrimoxazole was variable (53%-73%). All the MRSA isolates were sensitive to vancomycin. Thirteen (86.6 %) carriers were successfully decolonized with the local application of Mupirocin. However, two of the carriers did not take part in the further studies. Conclusion: The MRSA carriage rate among the HCWs in our hospital was high, particularly among the doctors and nurses. Screening and decolonization may be effective in decreasing the MRSA carriage rate among the HCWs. Standard infection control precautions should be employed in the professional practice to minimize either the carriage or the transmission rate.

Cyto-Histological Correlation of Thyroid Lesions with Estrogen and Progesterone Receptor Status on Neoplastic Lesions

Introduction: Thyroid nodules are common clinical findings, they are more common in women and this incidence increases with age, a history of radiation exposure and with a diet which contains goitrogenic material. Fine needle aspiration cytology (FNAC) is an established technique for the investigation of thyroid nodules. The aim of the present study was to establish a correlation between the cytological features and the histomorphology of various neoplastic and non-neoplastic lesions. Secondly, we aimed to analyze the oestrogen receptor (ER) and the progesterone receptor (PR) status in malignant thyroid tumours. Materials and Methods: The FNAC of 448 thyroid lesions was performed, with the histological correlation being available in 122 cases, over a period of 5 years. Immunohistochemistry was performed on the neoplastic lesions by the peroxidase- anti-peroxidase technique by using a mouse monoclonal antibody clone. Results: A cyto-histological discrepancy was noted in 8 cases. On considering histological diagnosis as the gold standard, the overall accuracy was found to be 92.9%.The male:female ratio was 1:7.2 and the maximum number of cases belonged to the nodular colloid goiter category (82.36%). An immunohistochemical analysis for ER and PR was performed on 11 cases of thyroid malignancy, with a single case of papillary carcinoma showing focal nuclear positivity for the progesterone receptors. Conclusion: The focal nuclear PR positivity which was seen in a single case cannot predict the biological behaviour of the tumour and thus, the use of anti-oestrogenic drugs like tamoxifen is questionable for the management of thyroid cancer. This needs to be confirmed further by taking up similar studies with a larger number of cases.

Comparison of Oral Clonidine and Midazolam as Premedications in Children

Rubina Khullar Mahajan, Iqbal Singh, Amar Parkash Kataria

Background: Oral premedication is widely being used in paediatric anaesthesia to reduce the pre-operative anxiety and to ensure a smooth induction. Midazolam is currently the most commonly used premedicant in children. Clonidine, an alpha-2 agonist due to its sedative properties, is also being used. Aim: The aim of the present study was to compare the clinical effects of oral midazolam and oral clonidine. Settings and Design: This study was conducted as a single blind trial on 60 children who were in the age group of 2-8 years. Methods and Material: The children were randomly divided into two groups and they were given either clonidine 4 mcg/kg (Group I, n=30) or midazolam 0.5 mg/kg (Group II, n=30) orally, which were dissolved in honey and water solution, 60 minutes prior to the mask induction. The drug acceptance, pre-operative sedation and anxiolysis, parental separation, quality of induction and mask acceptance, the effect on the haemodynamics and the adverse effects were evaluated. Statistical Analysis Used: All the values were reported as range and mean±SD. The data analysis for the numerical data was performed by the unpaired Student’s t-test and for the categorical data, the analysis was performed by the Fisher’s exact test or the Chi-Square test. Other data were reported as mean ± SD or frequency (%). A p value of≤ 0.05 was considered as statistically significant. Results and Conclusions: Oral clonidine tasted significantly better than oral midazolam. The onset of the sedation was significantly faster after the premedication with midazolam (30.5 ± 10.8 minutes) than with clonidine (38.5 ± 12.26 minutes). A satisfactory sedation could be achieved with both the drugs, but the quality of the sedation was significantly better after the premedication with clonidine. The difference in the onset of the anxiolysis was found to be statistically insignificant. A satisfactory anxiolysis was achieved with both, but the quality of the anxiolysis was better with clonidine. The quality of the mask induction was equally satisfactory in both the groups. A steal-induction was performed on 56.7% of the patients of the clonidine group, but on none in the midazolam group. No adverse effects like bradycardia, hypotension, hypoxaemia or apnoea were observed during the peri-operative period in both the clonidine and the midazolam groups. We concluded that oral clonidine is a good alternative to oral midazolam as a premedication in children.

A Clinical Study of Ectopic Pregnancy

Rashmi A Gaddagi, A.P. Chandrashekhar

Background- Motherhood- An eternal, universal and inherent dream which every woman has. This dream may not always be pleasant and it can involve nightmares. One of this is ectopic pregnancy – a pregnancy which can be life threatening . The present study involves a study on all the cases of ectopic pregnancy who were admitted to the Cheluvamba hospital during November 2004 to May 2006. OBJECTIVES 1. To know the age group, parity and the risk factors with re¬spect to the ectopic pregnancy. 2. To know the clinical presentation of the ectopic pregnancy. 3. To know the outcome of the ectopic pregnancy. Materials And Methods- A total of 37 patients who were di¬agnosed as ectopic pregnancy cases were analyzed between the period from November 2004 to May 2006. All these cases were analyzed after applying the inclusion and exclusion criteria with respect to the 1. History 2. Clinical presentation 3. Investigations 4. Treatment Results- The incidence of the ectopic pregnancy in the pres¬ent study was 1:399 pregnancies . A majority of the cases were multigravidas. In most of the cases, there were no identiable risk factors. However, they did present with pain in the abdomen, amenorrhoea and bleeding per vagina in at least 50% of the cases. Almost half (40%) were in a state of shock at admission. Ultrasound , a urine pregnancy test and culdocentesis were the investigative modalities which were used. All the cases were managed by surgical management. On laparotomy, a majority of the cases were found to be ampullary pregnancies, followed by interstitial pregnancies. The tube was ruptured in almost 80% of the cases and there was a haemoperitoneum. Almost all the patients had intraoperative and/ or postoperative blood transfusions. There was no significant post operative morbidity in these cases. Interpretation And Conclusion- The early diagnosis of an ectopic pregnancy is one of the greatest challenges for a physician. It requires a high index of suspicion i.e to diagnose an ectopic pregnancy, one must be ectopic minded .The im-portance of an early diagnosis lies in the fact that the lady can be offered a conservative line of management which can definitely have a beneficial effect on her reproductive career.

The Characteristics of Drug Wastage at the Hospital, Tuanku Jaafar Seremban, Malaysia: A Descriptive Study

Objective: To identify the types and the costs of medication wastage. Methods: Excessive or extra medicines were collected from visiting hypertensive patients, from their houses. The medications were listed and the cost was calculated by using the cost price from the Integrated Store Hospital, Tuanku Jaafar Seremban, Malaysia. The returned medicines from the volunteer patients that were collected at the pharmacy counter in the hospital were listed and the cost was calculated by using the cost price. This study was conducted from June to November 2007. Results: A total of 20,799 excessive pills were collected, with an average of 202 pills per patient from visited hypertensive patients. The total cost which was lost or wasted was MYR 4,362.28, with the average wastage being MYR 42.35/patient. A total of 131,098 pills were collected from volunteers at the pharmacy counter, with an average of 21,850 pills per month. The total cost which was lost or wasted was MYR 59,566.50, with the average wastage being MYR 9,927.75 per month. Conclusion: The data on the patients’ adherence and medicine wastage may provide useful information to the Ministry of Health with regards to the selection of the first-line medication which was recommended, based on the need to maintain a patient on a given treatment. Pharmacists should clearly explain the patients how to use their drugs and guide them through their initial periods of therapeutic inactivity and transient side-effects.

QTc Changes in Non-pregnant Females with Severe iron Deficiency

Vitthal H. Khode, K.F. Kammar

Background: A prolonged QT interval is a biomarker for ventricular tachyarrhythmias and a risk factor for sudden death. It is associated with a faulty storage of excess iron in the myocardium, which is described in several hereditary and acquired conditions. However, we do not have enough evidence on the fact that iron deficiency can affect the QT interval. We hypothesized that iron plays an important role in the generation and the propagation of electrical impulses at the level of the myocardial membrane and that it alters the QT interval; so we recorded the QT interval in severely anaemic, non-pregnant females and compared it with that in age and sex matched controls. Methods: 30 non-pregnant females with severe iron deficiency anaemia, Haemoglobin- <6gm% and low serum ferritin levels were subjected to the ECG test. The QTc of each subject was calculated by using Bazzet’s formula and this was compared with that of an equal number of sex and age matched controls. Results: A significantly shortened QTc was observed in severe iron deficiency anaemia (SIDA) (390±23ms) as compared to that in the controls (419±19ms) (P>0.001). There was a significant positive correlation between the serum ferritin levels and the QTc interval. Conclusion: A shortened QTc was observed in the SIDA group because of the sympathetic over activity which was secondary to the hyper dynamic circulation.

A Comparative Survey of Medical Disorders in the Elderly Persons of Rural and Urban Area of North India

Vinod Kumar Singh, Farhan Ahmad Khan

Aims of the Study: To study the profile of medical disorders in the elderly persons who attended the medical outpatients department in a tertiary care hospital. Methodology: This study was conducted in the Out-Patients Department of Medicine in the Teerthanker Mahaveer Medical College Hospital and Research Centre for a period of 6 months and a total of 380 consecutive patients who were aged 60-years and above were enrolled in it. The data from these patients was collected by taking a detailed history and by conducting a physical examination as per the pre-designed proforma. The relevant investigations were done, wherever needed. Results: Among the 380 patients, male patients (52.63%) predominated the female patients (47.37%). A majority of our patients were from the 60-70 years age group [82.00% (n=200) among the males and 82.22% among the females]. The no. of male patients (n=120) from the rural areas was higher than the number of females and the number of female patients (n=90) from the urban areas was higher than the number of males. The prevalence of various medical disorders in this population was: chronic obstructive pulmonary disease – 24.21%, hypertension – 20.78%, pulmonary tuberculosis – 14.47%, coronary artery disease – 12.36%, diabetes mellitus – 12.63%, chest infection (non-tubercular) – 10.0%, cirrhosis of the liver - 3.42%. and various types of cancers – 2.10%. Conclusion: The study showed a high prevalence of chronic obstructive pulmonary disease, pulmonary tuberculosis, hypertension and coronary artery disease in the elderly persons who attended a large tertiary care teaching hospital in Moradabad, UP.

The Role of Magnesium Sulphate in Tuberculous Meningitis

Context: Magnesium sulphate (MgSO4) has been studied for its beneficial role in traumatic brain injury (TBI) and ischaemic cerebral infarcts as it decreases the oxidative stress and increases the cerebral perfusion. The present study was done for evaluating its role in tuberculous meningitis (TBM). Aims: To study the role of intravenous magnesium sulphate in tuberculous meningitis. Methods and Material: The present study had 40 cases of tuberculous meningitis which comprised of 20 cases of group A(n-20) as contols for the study group B (n-20). The study group (Group B) was given intravenous magnesium sulphate 2 gm six hourly for 7 days additionally than the control group (Group A) which was treated with steroids and anti-tubercular drugs. The outcome was measured by using the Barthel Index (BI) and the Modified Rankin Scale (MRS) on the first day, the seventh day and after six weeks. The cases with arteritis in the two groups were compared separately. Statistical analysis: The results were analyzed by using the SPSS software and the unpaired t-test with p-values. Results: The means of the changes in the MRS and the BI of the Groups A and B were not statistically significant. When the means of the changes in the BI and the MRS were compared in the arteritis cases of the two groups separately, they were found to be statistically significant with a p value <0.05. Conclusions: Magnesium sulphate had a statistically significant role in TBM with tuberculous arteritis and it had a statistically nonsignificant role in TBM without arteritis.

Prevalence of Stress among International Post-graduate Doctors at the University Malaya Medical Centre (ummc), Kuala Lumpur

Omer Mohd Hussein, Nor Zurida bt. Zainal, Mohamed E Abdel-Latif

Background: The stress which affects the doctors is receiving increased attention. Researchers have shown that hospital doctors are under high levels of stress from a number of sources. This is of importance because it is known that the quality of care that the physicians give is directly related to their own health. Objectives: To study the prevalence of stress among international postgraduate doctors at the University Malaya Medical Centre (UMMC), Kuala Lumpur. Methodology: Post-graduate doctors completed General Health Questionnaires (GHQ-28) which covered Somatic Symptoms, Anxiety and Insomnia, Social Dysfunction and Severe Depression. The results were converted into a percentage scale by summing the scores of the individual items; in this overall scale, higher scores indicated increased stress. A total of 50 international doctors from different clinical and non-clinical medical subspecialties took part in the study. Results: The prevalence of stress among the international doctors was 54% (95% CI: 44–63%). The highest levels of stress were reported for “Anxiety and Insomnia” and the lowest level was reported for “Severe Depression”. Furthermore, the individual questions analysis revealed the highest scores for three questions: “felt constantly under strain”, “been feeling well and in good health” and “been managing to keep yourself busy and occupied”. Conclusions: The results should be interpreted with caution, as the study is based on a small sample. However, it does provide a useful first insight into stress and dissatisfaction, which have important implications for the wellbeing of international post-graduate doctors.

The Pattern of Glomerulonephritis in the North Indian Gangetic Plain- A 13-Year Epidemiological Study

Introduction: Epidemiologic studies, along with clinico-pathologic correlations, are important indicators which can be used for defining the burden of a particular disease and also to ascertain the trend of that entity, in order to monitor it according to the population which is at risk. Methods: The present study was undertaken over a period of thirteen years and it comprised of 226 patients at a single tertiary care centre in the northern part of India, so as to take a glimpse at the pattern of the disease in an area which had poor human development indices in comparison to the rest of India. Four percutaneous core (specimen) biopsies were retrieved after the ultra-sonographic localization of the kidneys in each individual case and these were subjected to light microscopic studies. The patients complaints and the complications post procedures were noted. Results: There were 139 (61.50%) males and 87 (38.49%) females, with a male to female ratio of 1.5:1. The post procedure complications which were recorded were local pain at the biopsy site in 3.8% patients, loin to groin pain in 1.9 % patients and gross/ microscopic haematuria in 0.9% patients. The indications which required the performance of the biopsies among the different age groups were nephrotic syndrome (121 patients; 53.53%), nephritic syndrome (66 patients; 29.20%), renal failure of unknown aetiology (29 patients; 12.83%) and asymptomatic haematuria (10 patients; 4.42%). Of all the glomerulopathies, membranous glomerulonephritis (MGN) was the commonest morphological pattern (13.27%) which was noted, followed by end stage renal disease (ESRD)-12.83% and mesangioproliferative (MeGN)-8.84% and membranoproliferative glomerulonephritis (MPGN)-7.96% respectively. Conclusions: The significant point which was noted in the present study was that the second commonest lesion which was seen on the biopsy specimen was that of ESRD (12.83%). In contrast to the findings of our study, ESRD was found to be not prevalent to such a degree in other studies which were done at other various geographical regions of India. Although ESRD was the second most common lesion which was found in the present study, a relatively high incidence in this area provided an insight into the challenges which were faced by the clinical nephrologists in the diagnosis and management of glomerular diseases in resource challenged countries.

A Prospective Study of Children Who were Admitted for Diabetes Mellitus at a Jamaican Hospital

Dalip Ragoobirsingh, Donovan Anthony McGrowder

Background: Type 1 diabetes mellitus is the predominant form of youth onset diabetes, and a majority of hospital admissions of this group of patients is usually due to a poor control of diabetes. Objective: This study was undertaken to determine the prevalence of type 1 diabetes mellitus in children who were admitted to the Bustamante Hospital for Children in Jamaica over a ten year period. Methods and Materials: A medical records study was conducted over this ten year period. Results: These showed that there were 77,679 admissions, of which 85 were for type 1 diabetes mellitus. Fifty (50) percent of the latter was between 8-12 years old. Female diabetic patients were twice as that of the males. Conclusion: It appears that one in every thousand children who were admitted to this institution were admitted for type 1 diabetes mellitus, and that girls between the ages of 8-12 years were more at risk.

Serum 25(OH)D and Type 2 Diabetes Mellitus

Background: 25(OH) Vitamin D is the circulating form of vitamin D which is measurable in the blood. Vitamin D insufficiency has been defined as serum 25-hydroxyvitamin D (25(OH) D) levels below 30 ng/mL and it is common among patients with type 2 diabetes mellitus (DM). Aim and Objectives: Our aim was to investigate the clinically meaningful associations which implicated low serum levels of 25(OH) D with impaired diabetic control in DM type 2. Methods: The serum 25(OH) D and the HbA1c levels were determined in 50 patients with DM type 2, along with their FBS, PPBS and HBA1c and other parameters which were required to assess the diabetic control were also measured. Results: The results of our study revealed a trend towards an inverse vitamin D - FBS (Pearson correlation, r = -0.090) and inverse vitamin D – PPBS (Pearson correlation, r = -0.095) association. The lower serum 25(OH) D levels were associated with the higher HbA1c levels (Pearson correlation, r = -0.173). This was a borderline association which may have probably occurred due to the small sample size. Conclusion: The association between the low serum 25(OH) D levels and elevated HBA1c in the study population may be inscribed into a wider context, portraying vitamin D insufficiency as a poor prognostic factor, which may play a vital role in impairing the glycaemic control.

A Study of the Interparietal Bones

Neeru Goyal, Madhur Gupta Bindu Aggarwal

Background: The squamous part of the occipital bone has an upper membranous part which is called as the interparietal part and a lower cartilage part which is called as the suboccipital part. There is a controversy regarding the ossification of these two parts. Aim: In this study, the incidence of the interparietal bone has been estimated and compared with the previous observations. Materials: A total of 150 adult dried skulls were examined to determine the incidence of the interparietal bone. Results: The skulls which were observed, displayed many variations in the occipital region. In 11 cases, single or multiple separated bones were observed. In 6 (4%) cases, the lower edge of these additional bones was situated slightly above the external occipital protuberance and such bones could be classified as interparietal bones. In 5 (3.3%) cases, the lower edge of these additional bones was much higher (higher than the midline, between the lambda region and the highest nuchal line). These bones were much smaller in size. The latter can be classified as either pre-interparietal or sutural bones or as non-fused parts of the interparietal bone. Further studies are required to clarify the origin of these bones.

Effects of Isotonic Exercises on Pulmonary Function and Free Radical Status in Healthy Young Adults: A Prospective Cohort Study

Vimal singh Gusain, Desh Deepak, Anant Narayan Sinha,

Background and Aims: Different types of exercises affect body systems in variable manner. The present study was undertaken to assess the effect of isotonic exercises, yoga and aerobics on pulmonary functions and free radical status in healthy young adults. Methods: The prospective cohort study was conducted in the departments of physiology and biochemistry at a teaching hospital in north India. Thirty subjects, 18-30 year old apparently healthy volunteers were included in 2 groups, aerobic and yogic, based upon regular performance of exercises. The subjects were assessed at the start of and after 3 months and 6 months of the training schedule. The parameters assessed were pulmonary function tests (FVC, FEV1, PEFR) and estimation of free radicals, malondialdehyde (MDA) & super oxide dismutase (SOD). The results were compared using student ‘t’ test & ANOVA. Results: The subjects in yoga group showed significant improvement in FEV1 & PEFR and in MDA and SOD level from baseline to 3 months. In the aerobic exercise group a significant change was observed in terms of FVC, FEV1 & PEFR, MDA & SOD at 3 months. No further significant change was observed from 3 to 6 months in any parameter among both groups. Conclusions: Though the observations suggest clear effect of isotonic exercises and various parameters, a further study with larger sample size and assessing more objective parameters can provide better insight into the suggested relationship.

Comparison of the Siriraj stroke Score and the Guy’s Hospital Score in South India

Background: CT scan is an important tool in stroke management. Due to its poor availability, we need to look for a simple but reliable scoring system to differentiate the ischaemic from the haemorrhagic strokes in our country. Aim: To compare the effectiveness of the Siriraj stroke score and the Guy’s hospital score for differentiating the ischaemic from the haemorrhagic strokes. Settings and Design: This study was conducted in a tertiary care centre in south India. This was a cross-sectional study. Methods and Material: The Siriraj stroke score and Guy’s hospital score were applied to 100 stroke patients and their results were compared with the CT scan results. Statistics: The sensitivity, specificity and the positive and the negative predictive values for both the scores were calculated separately. The Mc Nemar test was then used to compare both the scores. Results: The Siriraj stroke score had a sensitivity and a specificity of 87.93% and 77.27% for ischaemic strokes and for the haemorrhagic strokes, they were 77.27% and 87.93%. The Guy’s hospital score had a sensitivity and a specificity of 94.54% and 80% for ischaemic strokes and for the haemorrhagic strokes, they were 80% and 94.54%. The Mc Nemar test which was used to compare both the scores gave a value of X2=0.25 (p=0.61).This showed that there was no significant difference between the two scores in differentiating the ischaemic from the haemorrhagic strokes. Conclusion: There were no significant differences between the two scores when it came to differentiating the type of stroke. However, both the scores lacked the accuracy which was required for them to be applied and for guiding the physicians in stroke management.

Length of the Anterior Cerebral Artery (ACA) on MRI Angiograms

Magnetic Resonance Imaging, by far, has been found to be the most sensitive and non-invasive method for detecting angiographic images on the circle of Willis. The length of the vessels which form part of the circle of Willis is important for neurosurgeons while they perform various neurological procedures. It also helps the radiologists in interpreting the angiographic images in a better way. The length of the vessel also affects the haemodynamics of the vessel, thus affecting the major role of the circulus arteriosus as an anastomotic channel. Though many studies have been conducted on cadavers to measure the length of various cerebral vessels, not much work has been done on the length of the vessels by using modern techniques like MRI. The vessel length in the circle of Willis on MRI has not been reported, especially in this region of north India. This study was conducted on 120 normal angiographs which were taken by magnetic resonance angiographic techniques. In the results which were obtained in the present study, the length of the vessel was found to be higher on the left side. The range of the length on the right side was 10.4mm - 27.54mm, the mean length being 15.78mm ± 3.71mm, whereas on the left side, the range of the length was 10.6mm - 31.96mm and the mean length was 17.37mm ± 4.84mm . The present study gave the length of the anterior cerebral artery according to the side. In view of this, the length which is presented here may provide reference values which are specific to the three dimensional time of flight MRI angiography and it may be of value in the investigation of other pathologic features of the circle of Willis.

A Prospective, Double-blinded, Crossover Study to Determine the Equivalence of the Serum Levels and the Peak Level Toxicity of Diphenylhydantoin (EptoinR)

S. Bhuvaneshwari, Sujith Chandy, Sudhir Kumar,

Context: In India, phenytoin is often prescribed as twice daily or thrice daily dosage schedules. In the West, this practice has been changed to a once daily regimen in most of the cases. Can we in India follow suit? Is our physical and genetic make up with regards to the phenytoin pharmacokinetics different? Does this necessitate a multiple dosing regimen to avoid adverse effects or even breakthrough seizures? Aims: This study was aimed at comparing 300mg once daily of phenytoin and 100mg tid of phenytoin in terms of its adverse effects, peak and trough serum concentrations. Settings and Design: Out patients attending the Neurology Department, Christian Medical College, Vellore, India. This was a prospective, randomized, double blinded, crossover study. Methods and Materials: Twenty-four patients were enrolled into the study. An informed consent was taken from them. Their liver and renal functions were checked. Their basal phenytoin levels were also estimated. Once the preliminary tests were found to be normal, the patients were inducted randomly into one of the two treatment arms, either 300mg once daily or 100mg thrice daily. Each arm was given for a 2 week period. Adverse effects were looked for and the peak and trough phenytoin concentrations were estimated. Statistical Analysis Used: The mean, SD and the P values were obtained by the Per Protocol and the ITT (Intention to Treat) analysis of the trough and peak serum levels by using Wilcoxon’s signed rank test. Results: One patient experienced an adverse effect in the once daily regimen as compared to no adverse effects in the tid regimen. The adverse effect was not consequential to the patient. Statistically, the trough concentrations were not significantly different between the regimens, although the peak concentrations of the once daily regimen were significantly higher. Conclusions: In conclusion, it can be said that the once daily regimen can be prescribed for Indian patients with epilepsy.

Fructosamine in Non-diabetic First Degree Relatives of Type 2 Diabetes Patients: Risk Assessor

Introduction: A positive family history of diabetes increases the chances of developing the disease manifold. The earliest diagnostic marker for diabetes is elevated plasma glucose levels. Glycosylated haemoglobin (HbA1c) gives information on the long term control of diabetes, while the estimation of fructosamine (FA) depicts the short term glycaemic control. The specificity of the estimation of fructosamine and its comparison with the established markers in a group with high risk for the disease was the purport. Methods: 23 non-diabetic first degree relatives of type 2 diabetics (Group 2) were compared with 20 healthy controls (Group 1) and 23 type 2 diabetic people (Group 3). Fasting plasma glucose (FPG), glycosylated haemoglobin (HbA1c), serum fructosamine and total proteins (TP) were estimated in fasting blood samples. The saliva was analyzed for fasting salivary glucose (SG), salivary fructosamine and total proteins. The body mass index (BMI), waist circumference (WC) and the blood pressure were recorded and compared. Results: Group 3 had significantly higher mean FPG (150.26mg/dl), HbA1c (8.23 %) and salivary FA (202.05 mg/dl) values. Group 2 was associated with elevated serum FA levels (533.62 mg/dl), increased serum FA/ total protein (TP) ratio and a larger WC. On correlation analysis, FPG correlated significantly and positively with HbA1c in all three groups and with WC and BMI (0.613 and 0.400 respectively) in Group 2 only. Conclusion: Serum FA foretells the development of diabetes in high risk populations, but it has less sensitivity in depicting chronic hyperglycaemia. Serum FA and WC could be useful predictors of the development of diabetes in ‘high risk’ individuals.

Homozygosity and Heterozygosity of the Pericentric Inversion of Chromosome 9 and Its Clinical Impact

Mohit Kumar, Atul Thatai, Shilpa S. Chapadgaonkar

Introduction: This paper presents a detailed study of inversion in chromosome 9 and its correlation with sub-fertility amongst 26 couples. Until now, there have been conflicting views on the clinical outcome of the pericentric inversion in chromosome 9. Many researchers consider this anomaly as a predisposing factor for infertility. Methods: In the present study, the karyotyping analysis of 500 couples was carried out to investigate the genetic basis for infertility in these subjects. Results and Conclusion: It was observed that a significant fraction (5.2%) of the total group had a pericentric inversion in chromosome 9 as the only known abnormality. The incidence of this abnormality in infertile patients was significantly higher than the reported value of 1%-3% in the normal population. Moreover, it was observed that the incidence of the inv (9) karyotype in the male patients was 2.5 times higher than that in females. These correlations clearly indicated that the inv (9) karyotype was not a normal karyotype but that it had a harmful effect on fertility.

Correlation of the Probiotic Cell Number ml-1 and the Cell Mediated Immune Response: an in Vitro Study

Aruna Bhatia and Mansimran Kaur Randhawa

The beneficial effects of probiotics have been related to their survival number in the gut. But on the other hand, the dead probiotics also show immunostimulation and antioxidant activity. Hence, this study was planned to evaluate the in vitro, cell mediated immune response of six probiotic strains by differing their cell number ml-1 viz. 1 x 106 cell ml-1 and 1 x 109 cell ml-1 by using pig splenocytes. Splenocytes which were incubated with the six strains separately at concentrations of 1 x 106 cell ml-1 and 1 x 109 cell ml-1 for 24 hours, were assayed to study the cell mediated immune response by employing the Nitroblue Tetrazolium Reduction test and the Inducible Nitric Oxide Synthase test and by studying the bactericidal activity. The results demonstrated that a substantial increase in the stimulation of the cells occurred by the effect of all the probiotic strains at both the concentrations i.e. 1 x 106 cell ml-1 and 1 x 109 cell ml-1.However, the stimulation of the splenocytes was invariably higher at the concentration of 1 x 109 cell ml-1.The study suggests that higher number of cells should be employed during animal experimentation with probiotics to get observable effects.

Evaluation of the Multinational Association for Supportive Care in Cancer (MASCC) Score for Identifying Low Risk Febrile Neutropaenic Patients at a South Indian Tertiary Care Centre

Background: Febrile neutropaenia prompts immediate hospitalization for its evaluation and the administration of empiric broad-spectrum antibiotics. It represents a major cause of morbidity, mortality and treatment costs in patients who receive chemotherapy. Risk stratification to identify the low risk patients is essential, as these patients may improve with outpatient treatment. This approach reduces the economic burden and thereby improves the quality of life. Objective: Evaluation of the Multinational Association for Supportive Care in Cancer (MASCC) score and also other factors for identifying the low risk febrile neutropaenic patients at a south Indian tertiary care centre. Materials and Methods: This is a prospective study which was done at a tertiary care hospital in Mangalore, from December 2009 to July 2011. The inclusion criteria were the histological diagnosis of malignancy, neutropaenia which was secondary to chemotherapy, an absolute neutrophil count of < 500/cumm3, oral temperature of >38.30C or >38 0C for 1 hour and age > 13 years. The patients were stratified, based on the MASCC score. Other clinical laboratory parameters were explored for identifying the low risk patients. Results: A total of 50 cases of febrile neutropaenia were documented; 13 in solid cancers and 37 in haematological cancers. Acute leukaemia was the commonest underlying malignancy (26 out of 50). Seventeen cases were clinically documented, 16 cases were microbiologically documented and in 17 cases, no cause was found. Bacteraemia was the commonest (8 out of 16) among the MDI and E coli was the commonest organism which was identified (5 cases). All the patients were classified, based on the MASCC score. The association of the MASCC score and its outcome in terms of the recovery of the counts were found to be statistically significant (p <0.001). Other factors which were found to be statistically significant in identifying the risk of complications were; tachypnea rate> 24/minutes (p <0.001), Temperature>1020F (p= 0.049), hypotension (BP) value of <90/60 (p<0.001), ANC< 50/Cumm3 (p <0.001), deranged renal parameters (p=0.05), bacteraemia (p=0.001) and the inpatient status (p=0.006). Conclusions: The MASCC score correctly identifies patients with low risk febrile neutropaenia.

Radiological Appearance of Molars: Do They Consistently Identify Babies of 33-36 Weeks Gestation?

Akatoli Sema, Rajeev Sethi, V.K. Bhatia, Jacob Puliyel

Background: Gestational age is calculated from the date of the last menstrual period (LMP) may not be accurate when the cycle is irregular. In a previous study on small sample of European babies, the appearance of the cusps of the deciduous molar teeth on radiographs was found to be useful for determining the gestational age. The accuracy of this method was not affected by intra-uterine malnutrition. We did this prospective study on a large sample of newborns in India to validate the findings. Materials and Methods: Chest radiographs taken within the first 3 days of life – when they included the mandible – were studied against gestational age. Dates as per LMP, confirmed by either ultrasound examination during pregnancy or by Ballard’s scoring after birth, were the standard against which tooth age was validated. Results: The area under the receiver operating characteristic (ROC) curve for the 1st molar was 0.933 (95% CI: 0.900 to 0.966) and that for the 2nd molar was 0.952 (95% CI: 0.920 to 0.983). Accuracy was only marginally affected by intrauterine malnutrition. Conclusion: Tooth age may be used to estimate gestational age. Like the findings of ophthalmic examination at birth, tooth age is only marginally affected by intrauterine malnutrition.

Quality Assessment of Immunization Programme for Children Under Five in Davangere Taluk of South India

Background: Although immunization coverage has increased in recent times in India, the quality of the Indian national immunization programme is still debatable. So, this study was conducted to assess the quality of documentation of immunization and health education to mother during Expanded Programme on Immunization (EPI) which is the national immunization programme of India and stresses on childhood Immunization against diseases of public health importance. The quality of maintenance of cold chain was also assessed in the study along with other factors. Method: This cross sectional study involved female Junior Health Worker (JHW) of Davangere taluk in South India as participants. These were selected based on lot quality assurance sampling (LQAS). Each Junior Health worker Female (initially called multipurpose workers) who did immunization was considered as 1 lot. The numbers of lots rejected were considered for analysis and if rejection was higher than the allowed defect (obtained from LQAS table) the quality was considered poor. Results: Identification of needed vaccine by the JHW was poor as determined by LQAS technique. Vaccination status of children and vaccine recommendation for sick children was poor. Care of vaccine was good except for contamination during loading. Vaccination technique practiced by female JHW of Davangere taluk was poor. EPI education given to mother had failed in many places by LQAS. Maintenance of cold chain and supply of vaccine was good. Knowledge about immunization process among service providers was 100% about all vaccine. Conclusion: The quality of immunization sessions were not up to the mark.

Clinical Prediction of Obstructive Sleep Apnea (OSA) in a Tertiary Care Setting

Objectives: To prospectively evaluate the utility of clinical parameters in snorers in predicting obstructive sleep apnea (OSA) or for prioritizing patients for overnight polysomnography (OPS). Period and setting: August 2004 to June 2006; Sleep Laboratory, Institute of chest Diseases, Medical College, Kozhikode Design: Loud habitual snorers with one other symptom suggestive of OSA were subjected to 10 channel overnight polysomnography. OSA was diagnosed as per American Academy of Sleep Medicine criteria. Parameters having significant association with OSA and subsequently, independent predictors were determined statistically. For continuous variables, cut off values were obtained. A decision model for prioritizing patients for OPS was devised based on the predictors. Results: 90 patients completed the study. 71 participants had OSA. Age, sex and neck circumference were the independent predictors of OSA with neck circumference having the greatest prediction value. The cut offs for age and neck circumference in predicting OSA was determined to be 50years and 15.5 inch respectively. Based on these predictors, a decision model for prioritizing symptomatic snorers waiting for OPS was formulated. Conclusion: Neck circumference >15.5 inches, age above 50years and male sex independently predicted the risk of OSA in our study group. Symptoms were insignificant predictors of OSA.

Relation Between the Uridine Diphosphate Glucuronosyltransferase 1A1 Polymorphism and the Bilirubin Levels in Sickle Cell Disease

Background: Genetic variations in the promoter of uridine diphosphate (UDP)–glucuronosyltransferase 1A1 (UGT1A1) may be associated with hyperbilirubinaemia and it appears to be a risk factor for gallstone formation. Aims: Our aim was to detect the correlation between the UGT 1A1 (TA)n repeats and hyperbilirubinaemia and gall stone formation in Indian sickle cell patients. Settings and Design:This was a cross-sectional study; which was carried in an autonomous tertiary care hospital. Materials and Methods: The study subjects were 50 sickle cell anaemia and 70 sickle cell β-thalassaemia patients who were diagnosed by HPLC. The haemogram of the patients was measured by using an automated cell analyzer, while the serum bilrubin measurement was done by using a Beckman- CX-9 auto analyzer. The presence of gall stones was detected by ultra sound examination. Statistical Analysis: ANOVA and the T-test were applied to compare the means of the groups. The allele frequencies were calculated according to the Hardy-Weinberg equilibrium. Results: The allele, 7/7 TA of the UGT1A1 genotype was more frequent in the sickle cell patients and it was associated with hyperbilirubinaemia and gall stone formation. Conclusions: The allele, 7/7 TA of the UGT1A1 polymorphism affects the bilirubin levels and the development of gallbladder stone in the Indian sickle cell patients.

A Renal Bezoar of Epicoccum nigrum: An Unusual Clinical Curiosity

Shenoy Suchitra M., Prabhu Laxman G.G. Baliga Shrikala, Bhat Ashok M.

A 27-year-old male with a history of previous Percutaneous Nephrolithotomy (PCNL) was admitted to a tertiary care hospital with fever and pain in the left flank. An ultrasonogram revealed left renal calculi with severe hydronephrosis. A DJ stent was deployed as the patient had clinical signs of sepsis. Once he was clinically stable, the patient was treated by redo PCNL. The material which was extricated from the collecting system revealed the presence of the fungus, Epicoccum nigrum. Although they were uncommon in the past, fungal infections of the urinary tract are apparently increasing in frequency because of the more aggressive endourological procedures. We are reporting this case to highlight the need for maintaining aseptic procedures during any surgical procedure, the use of imaging techniques and the treatment options which are available in cases of renal bezoars.

Isolated Renal Hydatid Cyst Mimicking Renal Cell Carcinoma: A Diagnostic Dilemma

Anshu Gupta, Shivani Kalhan, Manish K Singhal, Onis Singhal, Viplesh Kaur

Context : Hydatidosis due to Echinococcus granulosus is a parasitic zoonosis with worldwide occurence. The most common locations are liver and lung. Occasionally, it may mimic intra abdominal tumour. Aims: Hydatid disease of the urinary tract is uncommon, occurring in only 2 to 3% of all cases. This case is presented with the aim of highlighting a giant renal echinococcus cyst, misdiagnosed as renal malignancy on imaging. Setting: The misdiagnosis of renal carcinoma was made in the case of a 65-year-old man. Materials and Methods: The patient presented with colicky pain in right flank with fever, nausea and vomiting. Right kidney was palpable with leucocytosis and proteinuria. X ray abdomen revealed ring calcifications in right upper quadrant. Ultrasonography (USG) and computerised tomography (CTshowed a soft tissue mass in right kidney. Intravenous urography with conventional tomography 15 minutes after contrast demonstrated nil nephrogram in right kidney. CT findings were suggestive of renal cell carcinoma. Conclusions: Hydatid cyst can attain large dimensions and can easily be misdiagnosed as a tumour. Despite its rarity, hydatid disease should be considered in the differential diagnosis of renal space-occupying lesions.

An Isolated Splenic Metastasis of Melanoma which Masqueraded as a Pancreatic Pseudocyst

A 60-year old man presented with left hypochondrial pain. Magnetic resonance imaging showed a large cystic lesion in the left hypochondrium, in close relation to the tail of the pancreas and an infiltrating splenic parenchyma, which were suggestive of a pseudocyst. The lesion was excised and it was sent for a histopathological examination. The histopathological examination revealed secondary deposits from the melanoma and this was confirmed by a immunohistochemical analysis. We are reporting this interesting case of an isolated splenic metastasis of melanoma which masqueraded as a pancreatic pseudocyst on an imaging study.

Seborrhoeic Keratosis; A Rare Cause of Conductive Deafness

Banavasi S Girisha, Kamath D Shrinath P, Permi S Harish

Seborrhoeic keratoses is commonly seen in the head and neck region, but it rarely causes functional impairment. When it is present at the external auditory canal, it can cause conductive hearing loss, which needs to be corrected by excision. We are presenting a successfully treated case of seborrhoeic keratoses of the external auditory canal with a conductive hearing loss.

Saree Cancer: The Malignant Changes in Chronic Irritation

S. Lal, Jayanta Bain, A.K.Singh, P.K. Shukla

Skin cancers are relatively uncommon malignancies which have been seen worldwide; their incidence in India is less than 1% of all the cancers. The incidence of malignancy in scar tissues is 0.1-2.5%. Saree is a type of female costume and dhoti is a male costume which are unique to the Indian subcontinent. The persistent and the long term wearing of this costume results in depigmentation and glazing of the skin, acanthosis, scar and ulceration and subsequent, but very slow, malignant changes. The exact mechanism of the malignant transformation is unknown, but recurrent trauma over a long period with consequent interference with the healing process is a possible explanation. Very few papers have been published on saree cancer and no article on this topic is available on Medline and Pubmed. Khanolkar and Suryabai first described ‘dhoti cancer’ in 1945. We are presenting a rare case of saree cancer in a 70 year old women. She presented with an ulceroproliferative growth which measured 10 cm × 7 cm on the left loin, which turned out to be squamous cell carcinoma on biopsy. Wide excision with primary skin grafting was done. The post operative follow up of one year has shown her to be disease free.

Giant Angiomyolipoma of the Kidney with Perinephric Extension: A Rare Case

Vijay Kumar K.R., T. Arul Dasan

Angiomyolipomas (AMLs) are one group of benign tumours that are distinguishable radiologically. Because AMLs are composed of different tissues which include fat, muscle, vascular elements, and even cartilage, the fat in particular, may be detected radiologically. Angiomyolipomas, particularly when they are small, warrant no treatment. They are resected only when they are over 4 cm or when they are symptomatic due to the risk of bleeding.

Spontaneous Expulsion of an Asymptomatic Large Sub-mandibular Salivary Gland Calculus: A Case Report

Maninder Pal Singh Gill, Ajay Pal Singh

Sialolithiasis is the most common disease of the salivary glands and the sub-mandibular gland is the commonest one to be affected. Sialoliths commonly measure less than 10 mm in size and stones larger than that are considered to be of an unusual size. They usually present with pain, swelling and recurrent infections of the affected gland. Various treatment modalities, mainly surgical, have been described for their management. However, for small stones, medical therapy and spontaneous expulsion of the calculus have also been described. This case report describes a relatively large sized stone that was spontaneously expelled without any therapy and was asymptomatic also prior to its expulsion. The relevance of conservative medical therapy has been discussed briefly.

Primary Hydatid Cyst of the Breast Masquerading as a Fibroadenoma: A Case Report

MayankKumar Singh, D. Nath, Khusbu Agarwal

Hydatid disease can involve any viscera, but the lung and liver are the two most commonly involved organs. The primary localization of the hydatid cyst in the breast is extremely rare. Here, we are presenting a case of a breast lump, which after surgical excision, turned out to be a case of hydatid disease without the involvement of any other organ. So, the possibility of hydatid disease should always be considered in the case of cystic lesions of any organ, especially those in the endemic region. The best treatment modality is surgical excision without spillage.

Seminal Retention Syndrome with Cybersex Addiction: A Case Report

Manjeet Singh Bhatia, Anurag Jhanjee, Pankaj Kumar

Culture bound syndromes which present with symptoms which resemble somatization have been described. In the Asian countries, syndromes which involve the loss of semen (the ‘Dhat syndrome’), which present with physical and psychological symptoms are common. This is only the second case report which has described seminal retention. A 24- years old, unmarried male who presented with the symptoms of a somatization disorder, which was attributed to seminal retention and who developed cybersex addiction has been described. He responded to the treatment with fluoxetine 20mg daily. Seminal retention syndrome needs further exploration in the southeast Asian countries for its prevalence, presentations and treatment.

Villar’s Nodule: A Rare Case Report

Kuladeepa Ananda Vaidya, Prashanth Adiga, Lakshman.I.K

Villar’s Nodule or primary umbilical endometriosis is a rare condition, with an estimated incidence of 0.5 to 1% among all the patients with endometrial ectopia. Endometriosis remains a diagnostic and therapeutic enigma even today, largely due to its variable presentations. We are hereby reporting a case of primary umbilical endometriosis due to its rarity and unusual presentation.

Primary Mesenteric Gastrointestinal Stromal Tumour Presenting as Acute Abdomen: A Case Report

Lavanya Krishnagopal, Naveen kumar Bagavathula Jayakumar, Sudarshan Chougulae

Primary mesenteric gastrointestinal stromal tumours are uncommon neoplasms. These mesenchymal tumours present with non-specific clinical features. We are reporting a case of large primary mesenteric gastrointestinal tumour with an unusual presentation as acute abdomen.

A Rare Case of Fungal Osteoarthritis Which was Caused by Phaeohyphomycosis

Sunil Kumar Y., Ninan Kurian, Mathias Lawrence, Karnekar Vimal, Teerthanath S.

Thyroxine Containing Slimming Agents, a Threat to Life

Manish Chandey

The aim of presenting this case is to report the rare occurrence of thyrotoxic periodic paralysis in females induced by thyroxine abuse. Thyroxine containing remedies are commonly used as a slimming agent in obesity clinics. We are reporting a case of 32-year old female who was abusing levothyroxine as a slimming agent on advice of her gym instructor and had to be admitted in hospital with periodic paralysis after three months of thyroxine abuse. She was having hypokalemia along with flaccid muscle weakness of both upper and lower limbs. She was started on potassium supplements and she recovered completely within 24 hours and was discharged after 72 hours on propranolol with the advice to avoid thyroxine abuse.

Status Epilepticus in Idiopathic Hypoparathyroidism

Ravinder Garg, Ramandeep Singh Dang, Simmi Aggarwal, K.S. Kajal

Acute hypocalcaemia which is seen in critically ill patients or which is caused by certain medications usually does not require specific treatment. But chronic hypocalcaemia which is caused by hypoparathyroidism is usually a symptomatic and requires treatment. A 50-years-old female presented in status epilepticus. She had muscle spasms, carpopedal spasms, facial grimacing and papillo-oedema. Her serum calcium and PTH levels were markedly decreased and her serum magnesium levels were normal. The CT scan of her head revealed calcifications in the brainstem, cerebellum, basal ganglia and the corona radiata and her ECG showed a prolonged QT interval. A diagnosis of chronic hypocalcaemia with hypoparathyroidism was made. The patient gradually responded to calcium infusions, anti-convulsants and supportive treatment. She was discharged in a satisfactory condition after 20 days on oral calcium supplementations and anti-convulsants. This case highlights the importance of the parathyroid hormone and calcium measurements in patients who present in status epilepticus.

Chromoblastomycosis of the Face: A Rare Case Report from the District of Western Maharashtra, India

Background: Chromoblastomycosis is a non-contagious, chronic localized fungal infection of cutaneous and sub-cutaneous tissues caused by several species of phaeoid (ie. Dematiaceous) fungi. It usually known to occur following trauma with wood splinters and usually occurs on the hands, feet and legs. Diagnosis can be made by direct microscopic demonstration of pathognomic brown sclerotic cells in skin scrapings and a positive fungal culture, confirms the same. Case Presentation:A 40-years old male presented with complaints of slowly spreading raised hyperpigmented lesions, three in number over right side of face and solitary plaque over lip with mild scaling from last six months and it was not associated with itching. Patient did not have any history of injury over the face with wooden splinters. The patient was initially suspected to have Lichen planus and was treated accordingly. But condition of the patients did not improve. He was then sent for Microbiological diagnosis. Laboratory Diagnosis: The diagnosis of Chromoblastomycosis was made by demonstration of sclerotic bodies with transverse septa arranged in cluster on KOH examination. Isolation of Fonsecaea pedrosii on SDA confirmed Chromoblastomycosis. Conclusion:Although Chromoblastomycosis is very rare on the face, our case demonstrates the need for consideration of Chromoblastomycosis in the differential diagnosis of resistant verrucous plaques of the face. We report an unusual case of Chromoblastomycosis for the first time from the state of Maharashtra and probably second case from India.

Otogenous Temporal Lobe Brain Abscess Which was Caused by Enterococcus Faecalis : A Case Report

Latha R., Rajbhaskar R., Kavitha K., Senthil Pragash D., Vinod R.

Brain abscess is a serious life threatening complication of the otitis media. We are reporting here, a case of an otogenic brain abscess which was caused by Enterococcus faecalis in a 10 year old male child. Computerized tomography (CT) revealed a right temporal lobe abscess. Culture yielded a pure growth of Enterococcus faecalis. The patient was successfully treated with burr hole aspiration, broad spectrum intravenous antibiotic therapy and tympanomastoidectomy.

Intralabyrinthine Schwannomas: Review of Anatomy, Pathology, Clinical Features from an Imaging Perspective

Tashfeen Ekram, Spencer R. Koch, Rajan Jain

Cementoblastoma Which was Associated with the Maxillary First Premolar: An Unusual Case Report

Bal Reddy P., Shyam N.D.V.N., Sridhar Reddy B., Kiran G., Prasad N.

Cementoblastoma is a rare, benign, odontogenic tumour that tends to be associated with the roots of the mandibular first molars and which is seldom associated with the maxillary teeth. It usually affects young adults. We are reporting a case of cementoblastoma which was attached to the right maxillary first premolar, which was treated with the extraction of the tooth and surgical excision of the tumour mass.

The Problem of Cyanocobalamin Defeciency in a Developing Country Set-up and the Possible Solutions

R.S Bharatwaj

Mycetoma of Foot: MR Imaging Demonstrated the “Dot-in-Circle“ Sign

Upasana Ranga, Senthil Kumar Aiyappan, Saveetha Veeraiyan

We are reporting here, a rare case of mycetoma involving the left foot in a 36-year-old male, that was correctly diagnosed with the help of the characteristic “dot-in-circle” sign on magnetic resonance imaging.

Diastematomyelia with Spina Bifida Occulta and Bilateral Intrathoracic Kidneys

Maya Patiatil, Pratiati Nidhi Shilpapa Aditya, Shai Lendra Vasant Savale

A 7-year-old girl had presented with nocturnal enuresis. On investigation, she was found to have spina bifida, diastematomyelia and focal syrinx. on MRI the X ray of her spine showed scoliosis. Her intra venous pyelogram revealed bilateral intra thoracic kidneys.

Serum Testosterone in Physically Active Adolescent Males

R. Nandhini, Nabeel Nazeer