Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
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On Sep 2018




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Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Case report
Year : 2011 | Month : April | Volume : 5 | Issue : 2 | Page : 381 - 383

Massive subhyaloid haemorrhage as a presenting feature of Cryptococcal meningitis (CM) in Acquired Immuno Deficiency Syndrome (AIDS)

SHEETAL A SAVUR, UMA D KULKARNI

Ophthalomogy, Yenepoya Medical College, Mangalore

Correspondence Address :
Dr. Sheetal A Savur
Assistant Professor, Department of ophthalmology, Yenepoya
Medical College, Deralakatte , Mangalore 575003
Phone: 0824-2204672, Mobile : 09632352678
Email:sheetalsavur@gmail.com

Abstract

Cryptococcal meningitis is a life and vision threatening complication in patients with AIDS. Ocular morbidity usually occurs secondarily to intracranial involvement and may manifest as papillo-oedema, optic neuritis and optic atrophy. Our patient however, had an unusual presentation of unilateral subhyaloid haemorrhage, which has not been reported earlier. The visual loss in cases of CM is usually due to secondary optic atrophy or optic neuritis. Cases of AIDS, presenting with subhyaloid haemorrhage, should be investigated for CM. An early recognition and prompt management can prevent vision loss.

Keywords

Opportunistic infections, AIDS, diagnosis, visual loss, cerebrospinal fluid, subhyaloid haemorrhage, Cryptococcus Neoformans, papillo-oedema.

How to cite this article :

SHEETAL A SAVUR, UMA D KULKARNI. MASSIVE SUBHYALOID HAEMORRHAGE AS A PRESENTING FEATURE OF CRYPTOCOCCAL MENINGITIS (CM) IN ACQUIRED IMMUNO DEFICIENCY SYNDROME (AIDS). Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2019 Aug 26 ]; 5:381-383. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=April&volume=5&issue=2&page=381-383&id=1215

INTRODUCTION
The incidence of CM is increasing with the rising numbers of AIDS patients. The clinical presentation and the course of CM may vary, relating in part to the underlying medical conditions and the immune status of the host. Ocular involvement is usually secondary to intracranial involvement and commonly manifests as papillo-oedema. Subhyaloid haemorrhage is generally seen in anaemia, thrombocytopaenia and proliferative diabetic retinopathy. Unilateral visual loss due to subhyaloid haemorrhage, as a presenting feature of CM, is rare. It is important to rule out CM in any patient with AIDS, presenting with loss of vision due to subhyaloid haemorrhage. Ethics: Written informed consent was obtained from the patient for using his clinical data and the photo-documentation for scientific publication.

Case Report

I am discussing here, the case of a 35 year old, sexually promiscuous, unmarried male who was diagnosed to have retroviral disease and who was receiving Anti Retroviral Treatment (ART) for 2 months. He complained of a throbbing headache which was associated with loss of appetite and disturbed sleep. The symptoms began one and a half months back and worsened in 15 days. He noticed the blurring of vision in the right eye, one week before presenting to us. He was otherwise apparently healthy, with his systemic examination including his central nervous system, being within normal limits. His best corrected visual acuity right eye was 5/60, N12; left eye was 6/9, N8, with normal colour vision in each eye. The anterior segment examination of both the eyes was normal, with normally reacting pupils. Amsler grid testing in the right eye revealed metamorphopsia . The right fundus revealed fresh vitreous haemorrhage, established papillo-oedema, extensive peripapillary haemorrhage and a massive subhyaloid haemorrhage involving the fovea. (Fig.1) The left fundus revealed established papillo-oedema, peripapillary haemorrhages and dot haemorrhages in the macula and in the internal limiting membrane folds, with the absence of the foveal reflex. (Fig.2) Laboratory evaluation: Haemoglobin was 9.3gm%; otherwise, the complete haemogram was normal. The peripheral smears showed a microcytic hypochromic blood picture with leucopaenia. The liver and renal function tests were normal. The absolute CD4 count was 21.74 cells/mcl., the absolute CD8 count was 102 cells per mm3 and the CD4/CD8 ratio was 0.37 (normal range: 0.60 - 2.80). Abdominal and pelvic ultrasound revealed mild splenomegaly. CT scan and MRI of the brain showed a normal picture. A guarded lumbar puncture was done. The opening pressure was 25mmHg, with the patient lying down. The analysis of the CSF revealed sugar- 52mg/dl (normal range 50-80mg/dl) and protein-20mg/dl (normal range15-45mg/dl). The CSF for the India ink preparation was positive for Cryptococcus neoformans and the Z-N stain was negative for Acid Fast Bacilli. Gram staining did not show inflammatory cells or organisms. The cytological features of CSF suggested CM. The CSF culture was positive for Cryptococcus neoformans. A clinical diagnosis of ‘AIDS with cryptococcal meningitis, with bilateral papillo-oedema, with massive sub-hyaloid haemorrhage (Right eye)’, was made.The patient received intravenous Amphotericin B 25 mg in 5% dextrose OD for 2 weeks, along with oral Fluconazole 400 mg in divided doses for 8 weeks, followed by a maintenance dose of oral Fluconazole 200 mg/day. After one month, an improvement was noticed with the resolution of the headache, improvement in the vision to 6/24 and partial resolution of the subhyaloid haemorrhage, the disc oedema and the peripapillary haemorrhage. Further follow-up was advised.

Discussion

Cryptococcus neoformans is an encapsulated yeast and it reproduces by budding. Worldwide, the C neoformans serotype A causes the most cryptococcal infections in immunocompromised patients, including those in patients who are infected with HIV. Although C neoformans enters the body via the lungs, the CNS is the main site of clinically evident infection in both the immunocompetent and the immunocompromised hosts. CM is common in immunocompromised patients including those with HIV infections. It is usually seen with a CD4+ cell count which is less than 75-125 cells per mm.(1). The primary ocular manifestations include chorioretinitis, choroiditis,(2) retinovitreal abscess, neuroretinitis and endophthalmitis. The ocular involvement in CM is usually secondary to intracranial involvement and it may manifest as papillo-oedema, optic atrophy, and ophthalmoplegia.(3) Pseudotumour cerebri can occur in CM.(4) The mechanism is presumably defective CSF absorption at the level of the arachnoid villi, due to direct inflammation or in some cases, the raised CSF protein contributes to the failure of CSF absorption.(4) The present case had bilateral papillo-oedema with peripapillary haemorrhages. This may be a direct result of cryptococcal meningitis (5). A massive, sub-hyaloid haemorrhage is seen in severe anaemia and thrombocytopaenia,(6),(7). In this case, it occurred in the absence of these associations. One must therefore keep CM in mind as one of the rare causes of subhyaloid haemorrhage. Subhyaloid and vitreous haemorrhages generally result from the forward dissection of severe peripapillary haemorrhages, whereas the scattered posterior pole haemorrhages probably represent the central retinal vein compromise from the optic disc swelling . An increased intracranial pressure is accompanied by an elevated ophthalmic venous pressure (8). In addition, the severe disc swelling may interfere with the central retinal venous flow, as well as with the local capillary perfusion,(9). It seems that in our patient, it was likely that the retinal haemorrhages resulted from an unusually severe, central retinal venous pressure which was associated with the papillo-oedema. Loss of vision in the present case was the result of a massive subhyaloid haemorrhage and vitreous haemorrhage. Cryptococcal meningitis in HIV patients per se can cause either rapid or slow visual loss. The rapid visual loss is usually due to optic neuritis, with the direct invasion of the optic nerve by Cryptococcus neoformans. Papillo-oedema and raised intracranial pressure may cause a slow progressive visual loss. Bilateral blindness has also been reported after starting antiretroviral therapy in a patient with CM.(10) Optic atrophy which was secondary to papillo-oedema and visual failure, was the most important cause of morbidity among the survivors.(5) In the present case, an early management may have prevented the occurrance of the optic atrophy which was secondary to the papillooedema. The diagnosis of CM requires a high index of suspicion, especially where there is a dearth of standard medical laboratory facilities and expertise. The diagnosis also involves making the CSF smears, cryptococcal antigen (CRAG) detection in the CSF and/ or serum, and the culturing of C.neoformans from the CSF. The CRAG test is an extremely important diagnostic procedure. Cryptococcal polysachharides can be detected by the latex agglutination technique in the serum and the CSF of people with CM. CSF CRAG is locally produced in the subarachnoid space by the invading C. neoformans, but not by active or passive diffusion from the serum.(11) Positive CRAG in either the serum or the CSF, has more than 95% sensitivity and more than 95% specificity in the diagnosis of CM.(12) India ink staining is commonly used to identify C.neoformans on the direct examination of the CSF.(13) It is positive in more than 80% of the AIDS cases with CM. Imaging studies have little or no diagnostic significance in CM. Polymerase chain reaction (PCR): This test finds either the RNA of the HIV virus or the HIV DNA in white blood cells which are infected with the virus. PCR testing is not done as frequently as antibody testing, because it requires technical skill and is expensive. The PCR test is very useful to find a very recent infection and to determine whether an HIV infection is present when the antibody test results are uncertain. Combined therapy with oral fluconazole and intravenous amphotericin B has been the recommended treatment of choice for patients with disseminated or meningeal cryptococcosis.(14) Fluconazole has been found to be beneficial in the resolution of the papillo-oedema which is caused by cryptococcal meningitis. The recommended first-line treatment for people with AIDS and CM is based on the results of the Mycoses Study Group (MSG)/ AIDS Clinical Trials Group (ACTG).(15), (16), (17)ox It comprises the administration of amphotericin B, 0.7 mg/kg/day, plus flucytocin, 100mg/kg/day (in four divided doses), for 2 weeks of initial treatment , followed by fluconazole, 400mg/day for 8 weeks of consolidation treatment and 200 mg/day for maintenance or secondary prophylaxis, as the relapse rate is more than 50% within the first year. Studies by the California Collaborative Treatment Group (CCTG) and the MSG/ACTG have firmly established that oral fluconazole, 200mg/day, is the drug of choice for maintenance treatment. (18), (19), (20)

Conclusion

Our report indicates that papillo-oedema with unilateral subhyaloid haemorrhage, with vitreous haemorrhage, can be the presenting feature in a patient of cryptococcal meningitis with AIDS.

Key Message

Cases of AIDS presenting with subhyaloid haemorrhage should be investigated for cryptococcal meningitis.

References

1.
Rao NA. Acquired immunodeficiency syndrome and its ocular complications. Ind J Ophthalmol 1994;42:51-63.
2.
Biswas J, Gopal L, Sharma T, Parikh S, Madhavan HN, Badrinath SS. Recurrent cryptococcal choroiditis in a renal transplant patient. Retina 1998;18:273-76.
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Kestelyn P, Taelman H, Bogaerts J, Kagame A, Aziz MA, Batungwanayo J, et al. Ophthalmic manifestations of infections with Cryptococcus neoformans in patients with acquired immune deficiency syndrome. Am J Ophthalmol 1993;116:721-27.
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P D Cremer, I H Johnston, G M Halmagyi Pseudotumour cerebri syndrome due to cryptococcal meningitis J Neurol Neurosurg Psychiatry 1997 January ;62(1):96-98.
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Tan CT, Kuan BB, Cryptococcus meningitis, clinical-CT scan considerations. Neuroradiology 1987;29:43-46.
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Majji AB, Bhatia K, Mathai A. Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura. Indian J Ophthalmol 2010;58:234-6
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Rubenstein RA, Yanoff M, Albert DM. Thrombocytopenia, anemia, and retinal hemorrhage. Am J Ophthalmol 1968;65:435-9.
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Hayreh SS,Edwards J.Ophthalmic arterial and venous pressures:Effects of acute intracranial hypertension.Br J Ophthalmol 1971;55:649.
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Keane JR. Sudden blindness after ventriculography: Bilateral retinal vascular occlusion superimposed on papilloedema. Am J ophthalmol 1974;78:275-78.
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De Schacht C, Smets RM, Callens S, Colebunders R. Bilateral blindness after starting highly active antiretroviral treatment in a patient with HIV infection and cryptococcal meningitis. Acta Clin Belg 2005;60:10-2.
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Currie BP, Freundlich LF, Soto MA, Casadevall A. False negative cerebrospinal fluid cryptococcal latex agglutination testswith culture positive cryptococcal meningitis. J Clin Microbiol 1993; 31: 2519-22 (s)
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Tanner DC, Weinstein MP, Fedorciw B, Joho KL, Thorpe JJ, Reller L. Comparison of commercial kits for detection of cryptococcal antigen. J Clin Microbiol 1994;32:1680-84 (s)
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Grant AD, De Cock KM. ABC of AIDS: HIV infection and AIDS in the developing world. BMJ 2001;322:1475-78 (s)
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Battu RR, Biswas J, Jayakumar N, Madhavan HN, Kumarsamy N, Solomon S. Papilloedema with peripapillary retinal haemorrhages in an acquired immunodeficiency syndrome (AIDS) patient with cryptococcal meningitis. Indian J Ophthalmol 2000;48(1):47-9.
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van der Horst CM, Saag MS, Cloud GA, et al. Treatment of cryptococcal meningitis associated with acquired immune deficiency syndrome. National Institute of Allergy and Infectious Disease Mycoses Study Group and AIDS Clinical Trials Group. N Engl J Med 1997; 337:15-21 (s)
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JCDR/2011/1215

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