Phaeohyphomycosis: A study from tertiary health care center in North India

Objectives: Phaeohyphomycosis refers to infections caused by phaeoid/dematiaceous or darkly pigmented fungi. This study was undertaken to further increase our knowledge about the incidence of phaeohyphomycosis and its causative agents. Materials and Methods: The present study was conducted over a period of one and a half years (January 2018–June 2019) on specimens received from patients with varied clinical manifestations ranging from superficial infections, subcutaneous cysts, pneumonia, brain abscess to a disseminated infection. These specimens were processed in the Department of Microbiology for potassium hydroxide (KOH) examination and culture and in Pathology for cytology/histopathological examination (HPE). All specimens positive on direct examination for dark grey, brown or black fungi were included in the study. Results: A total of 20 specimens were confirmed as phaeohyphomycosis. Most of the patients belonged to the age group of 41 to 50 years. Male: Female ratio was 2.3:1. Trauma was the most common risk factor. Spectra of the isolated fungal pathogens comprised of Bipolaris species, Exophiala species, Curvularia geniculata, Phialemonium species, Daldinia eschscholtzii, Hypoxylon anthochroum, Phaeoacremonium species, Leptosphaerulina australis, Medicopsis romeroi, Lasiodiplodia theobromae, Eutypella species, Chaetomium globosum, Alternaria species, Cladophialophora bantiana and 2 unidentified dematiaceous fungi. Recovery from phaeohyphomycosis was seen in 12 patients, 7 were lost to follow up and one patient succumbed to the illness. Conclusion: Infections caused by phaeoid fungi can no longer be viewed as rare. In fact, phaeohyphomycosis can have myriad of presentations spanning from mild cutaneous infections to fatal brain disease. Therefore, a high index of clinical suspicion is needed to diagnose such infections. The primary treatment modality remains surgical removal of the lesion in cutaneous or subcutaneous infections however disseminated disease with a guarded prognosis requires aggressive management.

Incarcerated Cannulated Cancellous Screw Removal during Total Hip Arthroplasty with a Novel Trick: A Case Report

@#Salvage total hip arthroplasty (THA) may be required to manage femoral neck fracture implant failures, avascular necrosis and secondary hip arthritis. Cannulated cancellous screws can become stripped or incarcerated during the initial implantation and pose hardware removal issues. We present a novel technique for safe screw removal in a 62- year-old female patient with a painful right hip. She had undergone cancellous screw fixation for a fracture of the neck of femur ten years ago. There was avascular necrosis with screw cut out leading to secondary hip arthritis necessitating THA. Intra-operatively cannulated cancellous screw along the inferior femoral neck region was incarcerated. After posterior dislocation of the head, the neck was osteotomised, and the screw threads were exposed for possible extraction. However, the thickened femoral neck region with solid cortical bone prevented the screw disengagement in either direction. The screw along the femoral trochanter region was cut with a Harrington cutter and the remaining screw disengaged with careful removal of bony spicules and controlled anticlockwise rotations, to remove the screw in around fifteen minutes. Arthroplasty could be completed uneventfully thereafter. We could remove the screw while avoiding an iatrogenic fracture along the calcar region and excessive bone loss along the screw track. The femoral canal remained uncompromised. The anticipation of a difficult implant removal with a thorough understanding of the devices and techniques, is an invaluable asset to the operating surgeon. With a simple tool and novel technique in a difficult situation, we can save on operating time and minimise complications.

Prevalence of short segments of specialized columnar epithelium in distal esophagus: association with gastroesophageal reflux.

BACKGROUND AND AIMS: Recent studies have reported high prevalence rates of short segments of specialized columnar epithelium (SCE) in the distal esophagus. The association of SCE with gastroesophageal reflux disease is not well established. We studied the prevalence and associations of short segments of SCE in the distal esophagus amongst Indians. METHODS: 271 patients (mean age 36 [14] y; 160 men) undergoing diagnostic upper gastrointestinal endoscopy were interviewed regarding symptoms of gastroesophageal reflux, and history of medications, smoking or chewing tobacco and alcohol ingestion. At endoscopy, presence and grade of esophagitis and hiatus hernia were recorded. One biopsy each was taken from the squamocolumnar junction and 2 cm proximal to it. Biopsies were stained with hematoxylin/eosin and alcian blue/periodic acid-Schiff. The pathologist was blinded to the clinical and endoscopic data. RESULTS: Short segments of SCE in the distal esophagus were present in 16/271 (6%; CI 5.03-6.97) patients. Increasing age (p<0.01), and endoscopic (p<0.01) and histologic (p<0.001) esophagitis were associated with its presence, whereas symptoms of gastroesophageal reflux, smoking, tobacco chewing, use of alcohol or non-steroidal anti-inflammatory drugs, and hiatus hernia were not. One patient with SCE had dysplasia. CONCLUSION: Prevalence of short segments of SCE in the distal esophagus amongst Indians is low and is usually associated with inflammation in the esophagus.

Transmigrated mandibular permanent canine: a case report.

A case of transmigration of mandibular canine is presented. The importance of anesthetizing the transmigrated tooth from the side of origin is highlighted.

Laparoscopic gastropexy for chronic intermittent gastric volvulus.

The traditional surgical treatment of chronic gastric volvulus involves laparotomy for derotation of the stomach and its fixation to the patients. We describe a 36-year-old man with organoaxial gastric volvulus who was treated successfully with laparoscopic gastropexy. He is asymptomatic four months later.

High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis.

OBJECTIVES: The fregency of bacteremia after endoscopic variceal band ligation (EVL) is reported to be lower when compared to that after endoscopic variceal sclerotherapy (EVS). However, there are conflicting reports on the infectious sequelae after EVL. AIM: To compare the frequency on bacteremia and infectious sequelae after EVL and EVS in patients with cirrhosis of liver. METHODS: Bacteremia and infectious sequelae were studied in 32 sessions of EVL in 18 cirrhotic patients (Child-Pugh class A-6, B-5, C-7), 30 sessions of EVS in 22 cirrhotic patients (Child-Pugh class A-2, B-5, C-15) and 14 diagnostic upper gastrointestinal endoscopies. Blood cultures were collected before, during and 30 minutes after the procedure. Patients were observed for infectious sequelae during subsequent hospitalization. RESULTS: Before the procedure, bacteremia was present in 7/62 (11%) sessions. Significant bacteremia during and 30 min post-procedure developed in 8/32 (25%) and 12/30 (40%) of EVL and EVS sessions, respectively (p = ns), and in 1/14 (7%) upper gastrointestinal endoscopy sessions. There was more frequent bacteremia with severe liver disease (Child-Pugh class A-0/6, B-1/5. C-7/21; p = 0.09) in the EVL but not in the EVS group (Child-Pugh class A-1/3, B-2/5, C-9/22; p = ns). The incidence was higher with emergency sclerotherapy compared to elective sclerotherapy (6/8 [75%] vs 6/22 [27%]; p <0.01). One patient in the EVS group developed spontaneous bacterial peritonitis. CONCLUSIONS: Bacteremia occurs frequently following EVL and EVS in patients with advanced liver diseases. In the EVS group it is more common after emergency sclerotherapy. This bacteremia is rarely associated with significant infectious sequelae.

Prospective evaluation of medication-induced esophageal injury and its relation to esophageal function.

BACKGROUND: Few prospective studies are available on the incidence of medication-induced esophageal injury (MIEI). AIMS: To prospectively study the occurrence of MIEI with indomethacin and doxycycline and the predictive factors for its development. METHODS: In an operator-blinded study, 51 patients (age 16-65 y) requiring indomethacin (n = 24) or doxycycline (27) underwent symptom evaluation, endoscopy and scintigraphy before and after 7 days of therapy. MIEI was defined as de novo occurrence or worsening of pre-existing esophagitis or development of esophageal ulcer. RESULTS: Pre-therapy endoscopy was normal in 32 patients and revealed esophagitis in 19 (grade I--11, grade II--8). Post-therapy, 16 patients developed esophageal symptoms, which appeared earlier with doxycycline (2.0 [0.8] vs 4.1 [1.7] days, p = 0.016). MIEI developed in 23 patients--de novo esophagitis in 16, worsening of esophagitis in 6; 5 patients developed ulcer. Seven of 12 patients with hiatus hernia developed MIEI. Presence of pre-therapy gastroesophageal reflux disease did not predict MIEI. There was no difference in pre- or post-therapy transit values between patients with and without MIEI; patients who developed ulcers had significantly slower esophageal transit (p < 0.05). There was no difference in esophageal transit or occurrence of MIEI between patients who received indomethacin or doxycycline; however, 5 of 8 patients with hiatus hernia who received doxycycline developed MIEI (p = 0.02; relative risk 3.96 [CI 1.2-12.7]). CONCLUSIONS: 40% of patients receiving doxycycline or indomethacin developed MIEI; 10% developed ulcers. Hiatus hernia increased the risk for MIEI.

Barrett's esophagus.

Contrary to earlier definition of Barrett's oesophagus which referred to the presence of metaplastic columnar epithelium of either gastric or intestinal type, the new definition lays stress on presence of specialised columnar epithelium (SEC) with goblet cells. Hence this study was carried out to determine the frequency of specialised columnar epithelium in Indian population. 150 cases of dyspepsia underwent esophagogatro duodenoscopy with esophageal biopsy. Slides were stained with routine H and E stain and alcian blue-PAS stain. Histologically, esophagitis was found in 75 (50%) and columnar epithelium-gastric type in 63 (42%) cases only 4 (2.6%) cases showed presence of specialised columnar epithelium which were labelled as Barrett's esophagus, giving an incidence of 2.6% in this study.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine.

OBJECTIVES: Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied. METHODS: Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion. RESULTS: The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects. CONCLUSIONS: The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

Detection of anti-PPD IgG antibody and PPD-induced delayed type hypersensitivity in anterior uveitis patients.

Present study relates to the results of anti-PPD IgG, anti-A60 and antinuclear antibodies and PPD-induced delayed type hypersensitivity (DTH) in 17 anterior uveitis, (AU) patients. Results of anti-PPD IgG assay revealed detection of higher mean antibody level (O.D. 0.11 +/- 0.06) compared to healthy controls (O.D. 0.04 +/- 0.03), other eye disease controls (O.D. 0.05 +/- 0.003) and leprosy controls (O.D. 0.03 +/- 0.03). Anti-A60 IgM antibody assay revealed insignificant differences in mean antibody levels between various groups. Four of 17(23.5%) AU patients and 1(5.8%) subject each, belonging to other eye disease and healthy control groups had raised anti-nuclear antibody index. Findings of PPD skin test revealed detection of moderate to strong (2 to 4+) reactivity in 14 (82%). AU patients. Conversely, 13(76%) healthy controls and 8(47%) other eye disease controls gave mild (1+) reactivity. Results of this study suggested possible role of hypersensitivity to mycobacterial antigens in pathogenesis of anterior uveitis.

Prevention of gastrointestinal diseases.

The prevalence of gastrointestinal diseases markedly differs between developed and developing countries because of the poor sanitation, hygiene, impure water and food ingestion, widespread illiteracy and poverty in the developing world. The incidence of gastrointestinal diseases such as diarrhoea, cholera, typhoid, dysentery, viral hepatitis (A and E virus) can be substantially reduced by providing clean water and food to the population. Restricting consumption of tobacco and nonsteroidal anti-inflammatory drugs will reduce diseases and/or complications of the upper gastrointestinal tract. Diminishing alcohol intake and overuse of blood transfusion and improving blood banks would prevent many acute and chronic liver diseases. Costly passive and active immunoprophylaxis will become unnecessary if these measures are undertaken.

Role of routine estimation of creatinine clearance in patients with liver cirrhosis.

BACKGROUND: Frequent occurrence of renal dysfunction without azotemia in patients with decompensated cirrhosis, and its prognostic and therapeutic importance, are not well appreciated. METHODS: Creatinine clearance (CrCl), 24-hour urinary sodium excretion, fractional excretion of sodium, and urine flow were estimated in 68 non-azotemic uncomplicated cirrhosis patients; all these patients were followed up for a period of 6 months. Eighteen patients with ascites and edema were treated with large volume paracentesis without colloid replacement and renal function was evaluated before, and 48 hours and 7 days later. Eight patients with abnormal CrCl were treated with 10 mg of enalapril daily and CrCl estimated at the end of 7 days. RESULTS: Of 68 patients, 22 had CrCl > 80 mL/min (Group I), 21 had CrCl of 50-80 mL/min (Group II) and 25 had CrCl < 50 mL/min (Group III). Renal dysfunction correlated with Child's class. During a mean follow up period of 180 days, patients in Groups II and III had higher mortality rates than those in Group I (23.8% and 36.0% vs 9.1%; p < 0.001). Following large volume paracentesis, CrCl decreased at 48 h and continued to be low at the end of 7 days even though blood urea nitrogen and serum creatinine remained normal. CrCl improved with 10 mg enalapril at 7 days (46.5 +/- 15.4 to 73.2 +/- 19.7 mL/min; p < 0.05). CONCLUSION: More than two-thirds of patients with advanced cirrhosis have abnormal CrCl despite normal blood urea nitrogen and serum creatinine; they also have a higher mortality as compared with patients with normal CrCl. CrCl decreases after large volume paracentesis even though blood urea nitrogen and serum creatinine remain unchanged. Enalapril improves CrCl in patients with liver cirrhosis but its exact clinical utility needs further evaluation.

Alternate-day therapy with omeprazole for duodenal ulcer.

BACKGROUND: Maximal acid suppression produced by a single dose of 20 mg omeprazole has been reported to persist for over 24 hours, with acid secretion returning to normal after 2 days. OBJECTIVES: (i) To study the effect of single oral dose of 20 mg omeprazole on maximal acid output (MAO) and peak acid output (PAO) in duodenal ulcer patients and healthy volunteers. (ii) To compare the efficacy of omeprazole 20 mg daily versus 20 mg on alternate days in the treatment of duodenal ulcer. STUDY DESIGN: Open randomized comparative trial. METHODS: MAO and PAO were estimated in five duodenal ulcer patients and five healthy volunteers before, and 24 hours and 48 hours after, a single 20 mg oral dose of omeprazole. Fifty eight consecutive uncomplicated duodenal ulcer patients were randomized to receive omeprazole 20 mg either daily (n = 30) or on alternate days (n = 28) for four weeks. The two groups were matched for age, sex, duration of ulcer symptoms, smoking, NSAID use, and ulcer size at entry. Symptom scores using a pre-defined scoring system and endoscopic ulcer healing rates were evaluated at 2 and 4 weeks. RESULTS: MAO and PAO showed significant reduction in both duodenal ulcer patients and healthy controls 24 hours after 20 mg omeprazole. Reduction at 48 hours was significant in duodenal ulcer patients but not in controls. Endoscopic healing rates of duodenal ulcer at 2 and 4 weeks were 80% and 93.3% respectively in the daily treatment group and 71.4% and 85.7% respectively in the alternate-day treatment group. These differences were not statistically significant. CONCLUSION: 20 mg omeprazole on alternate days is as effective as 20 mg daily (i) in suppressing MAO and PAO and (ii) in the treatment of duodenal ulcer.

Stomach in portal hypertension.

365 consecutive patient of portal hypertension [Cirrhosis 285, Non-cirrhotic portal fibrosis (NCPF) 50, Extrahepatic portal vein obstruction (EHPVO)-30] were evaluated prospectively over a period of 2 years. Of these, 33 patients underwent successful sclerotherapy with evaluation before and after the same. Portal hypertensive gastropathy (PHG) was found in 56.4% (mild 28.2%, Severe 28.2%) of total patients; while its incidence was 60.6% in cirrhosis, 54% in NCPF and 20% in EHPVO. Incidence of PHG was significantly higher in cirrhotics when compared with non-cirrhotics (60.7% vs 41.25%: p < 0.05). PHG is more common in patients with large esophageal varices as compared to those with small varices (64.1% vs 50.8%: p < 0.05). Overall incidence of gastric varices was 29.3% while its incidence in cirrhosis, NCPF and EHPVO was 22.1%, 44% and 73.3% respectively. Incidence of gastric varices was significantly higher in non-cirrhotics (NCPF + EHPVO) when compared with cirrhotic (p < 0.05) and in patients with large esophageal varices when compared with patients having small esophageal varices (p < 0.05). Peptic ulcer was found in 10.9% patients with portal hypertension. (More than 90% were cirrhotics, mainly alcoholics). 33 patients underwent successful sclerotherapy of which 11 had PHG (mild--6, severe--5) at the beginning of sclerotherapy. After successful sclerotherapy 26 patients had PHG (mild--14, severe--12) p < 0.001). There was no significant difference in incidence of gastric varices before and after sclerotherapy. Incidence of PHG was significantly higher in cirrhotics while gastric varices were seen more commonly in patients with non-cirrhotic portal hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic ascites.

Pancreatic ascites is rarely considered in the differential diagnosis of exudative ascites, and is in fact missed in a majority of patients. Eleven cases of pancreatic ascites are described. 63.6% were chronic alcoholics. The clinical diagnosis was cirrhosis of liver (5/11), tuberculous peritonitis (5/11) or malignant peritonitis (1/11). In all patients ascites was exudative and the ascitic fluid amylase was markedly elevated (mean +/- SD: 7815 +/- 6507 SU/dl). Endoscopic retrograde pancreatography (ERP) performed in 4 patients demonstrated the site of leak in 3. Laparoscopy performed in 8 patients helped in the diagnosis of pancreatic ascites in all, which was confirmed on histology. Laparoscopy ruled out other causes of exudative ascites in all. We conclude that pancreatic ascites should be suspected in any patient with exudative ascites, especially chronic alcoholics and that ascitic fluid amylase should be routinely performed in all such cases. High ascitic fluid content is virtually diagnostic of pancreatic ascites. ERP is essential in preoperative assessment or planning endoscopic treatment. Laparoscopy is an invaluable investigation to rule out other conditions such as tuberculous or malignant peritonitis and cirrhosis of liver.