Causative fungi and treatment outcome of dematiaceous fungal keratitis in North India

Purpose: The aim of the study is to identify risk factors, clinical characteristics, causative fungi, and treatment outcome of dematiaceous fungal keratitis in North India. Methods: Consecutive cases of culture-proven dematiaceous fungal keratitis between January 2012 and June 2017 were retrieved from the medical record department. Risk factors, clinical signs, and outcome were registered. Results: Eighty-three patients were included. Identified dematiaceous fungal organism were Curvularia sp. (n = 55/83; 66.3%), Alternaria sp. (n = 12/83; 14.5%), Ulocladium sp. (n = 5/83; 6%), Bipolaris sp. (n = 5/83; 6.1%), Scedosporium sp. (n = 3/83; 3.6%), Acremonium sp. (n = 2/83; 2.4%), and Epicoccum sp. (n = 1/83; 1.2%). Male preponderance was reported. The most common predisposing factor was corneal trauma (67.4%). In cases associated with corneal trauma due to vegetative matter, sugarcane was the most common cause. In all, 89% of the patients were more than 30 years of age. The median infiltrate size was 8 mm2. The median time of antifungal therapy was 4.2 weeks (interquartile range [IQR]: 1-25 weeks). Complications were seen in 14 (n = 14/65; 21.5%) patients. Complete resolution of dematiaceous fungal keratitis was present in 27 (n = 27/65; 41.5%) eyes. Conclusion: Curvularia sp. and Alternaria sp. were the predominant pathogenic genera causing dematiaceous fungal keratitis. Among the causative fungi, infections due to Scedosporium sp. were associated with the worst outcomes. Ulocladium sp. and Epicoccum sp. were also identified. Both the species are not reported previously as a causal organism of dematiaceous fungal keratitis from North India.

Limbus Sparing Limbal Incision - A New Modified Conjunctival Incision Technique in Strabismus Surgery

The aim of the study is to introduce a newer technique of conjunctival incision called ‘Limbus Sparing Limbal Incision (LSLI)’ for horizontal rectus muscle strabismus surgeries. Methods: 20 patients were randomly divided into two groups of 10 each. In group 1, the conventional limbal incision was given in the conjunctiva and in group 2, a modified limbal incision, Limbus Sparing Limbal Incision (LSLI) was given. Each patient was followed post operatively on 1st, 7th and end of six weeks. Symptoms like pain, discharge, FB sensation, conjunctival congestion, excessive watering and lid swelling were noted. A record was also made of the conjunctival hyperaemia/chemosis, gaping in conjunctival incision, conjunctival retraction/coiling, thickened conjunctival flap, suture granuloma, corneal abrasion, dellen formation, other signs of ocular surface disorders, need for suture removal and need for resuturing. Results: The mean pain score in group 1 was 1.30 ± 0.68 and 2.10 ± 0.57 in group 2 (p=0.010). Mean foreign body sensation score in group 1 was 1.10 ± 0.32, and 2.30 ± 0.68 in group 2 (p<0.001). In 20% of patients in group 2, re-suturing of the wound had to be done. Dellen formation was seen in 10% of patients in group 1 and none in group 2 (p=1.0). Conclusion: Though, the new modified conj incision spares the damage to perilimbal tissue and stem cells, the post op discomfort and delayed healing limited its use. However, large scale studies are needed which can compare the two techniques in terms of outcomes, complication rates, and patient satisfaction.

An unusual case of hepatic lymphoma with multiple epithelial malignancies

Primary hepatic mucosa-associated lymphoid tissue lymphoma (MALToma) is a rare entity. Its coexistence with other malignancies is even rarer. Only few case reports of its association with other malignancies mostly gastric and colon cancer have been published. We report a case of primary MALToma of liver in an unusual setting of dual solid malignancy.

Infectious crystalline keratopathy post-Descemet stripping endothelial keratoplasty

We report a case of a 46-year-old female who developed infectious crystalline keratopathy (ICK) after Descemet's stripping endothelial keratoplasty (DSEK). She underwent DSEK for pseudophakic corneal edema in her left eye. Ten weeks after the procedure, the patient presented with complaints of blurred vision, redness in eye, and ocular pain. Slit lamp examination revealed white nonsuppurative branching deep stromal infiltrate. Microscopic examination of the Gram-stained smear showed gram-positive cocci. Streptococcus viridans was isolated on cultures. Isolated organism was sensitive to linezolid. Based on antibiotic sensitivity report, fortified linezolid (0.2%) eye drop was started on hourly basis. After 10 weeks of topical fortified linezolid (0.2%) therapy, complete resolution of infiltrate with significant corneal scarring and vascularization was seen. Infectious crystalline keratopathy can occur after DSEK.

Clinical profile of childhood blindness and inappropriate enrolment of children in schools for visually impaired in Uttar Pradesh, India

Purpose: To assess major causes of severe visual impairment (SVI)/blindness (BL) in children studying in schools for the blind in western Uttar Pradesh, India and the extent of inappropriate enrolment of children in blind schools. Methods: Students of five schools for the blind were examined in a tertiary care eye hospital. The anatomical sites and etiology for SVI/BL were recorded using the World Health Organization/Prevention of Blindness standard reporting form. Categorical variable were summarized using frequencies and percentages. Results: A total of 93 students were examined. Male/Female ratio was 3.4:1. The most common anatomical sites of SVI/BL were the whole globe (40.3%) and the cornea (26.4%). Postnatal or childhood causes were noted in 13.8% cases. Forty-one (56.9%) students had hereditary diseases which was most likely caused by chromosomal abnormalities. Three students were having an associated disability, one was deaf and mute, one was physically handicapped, and one was intellectually challenged. Fifty-four (58%) children were blind and 21 (22.6%) children had no visual impairment but were studying in schools for the blind. Conclusion: Schools for the blind should be screened routinely to reduce the incidence of misdiagnosed visual impairment. This will prevent inappropriate enrolment and will definitely help in reducing the social and economic burden of society and of the schools of blind too.

Potency dependent activity of homeopathic nanomedicine- classical and quantum electrodynamical approach

The effect of homeopathic medicine on biological and physical system is directly related to its potency [1]. However, from physico-chemical point of view it is difficult to explain this effect at such high dilution, as then the existence of even trace amount of particle is questionable. It has been reported that during the process of potentization, a large amount of mechanical energy gets transferred to the medium due to succussion [2]. This energy in all probability reduces the size of the drug aggregates. The drug then penetrates easily through the membrane barrier, and thereby gives rise to enhanced activity of the medicine. It has been experimentally proved by us and supported by others that indeed a reduction of size of the aggregates takes place with increase in potency [3]. Using five different homeopathic medicines, their sizes at three different potencies have been estimated and a general mathematical expression relating the size of the particle (Y) and the corresponding potency (X) has been derived as follows Y = a X -n. (AU)

Tuberculosis Lymphadenitis in a Well Managed Case of Sarcoidosis.

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

Peripheral Vascular Disease a Silent Assassin: Rising trend in State of Punjab.

Peripheral vascular disease is a major macrovascular complication of diabetes mellitus. This study was done to determine the prevalence of peripheral arterial disease in type 2 diabetes mellitus using the ankle brachial pressure index. An 12 MHz doppler probe was used in the arms and legs to assess the ankle brachial index (ABI) in 200 type 2 diabetes mellitus patients aged more than 40 years. Thorough history of patients including age, smoking history, history of symptoms of peripheral arterial disease, complete physical examination and routine investigations were collected at the time of enrolment for all subjects. A ratio of the highest blood pressure from the posterior tibial or pedal arteries of each leg to the highest blood pressure from the brachial arteries < 0.9 was considered abnormal. Abnormal ABIs were found in 33% (66/200) patients with type 2 diabetes mellitus. 45.5% patients had ABI 0.80–0.89, 33.3% patients had ABI 0.50–0.79 and 21.2% patients had ABI <0.5 Prevalence of peripheral vascular disease in type 2 diabetes mellitus is on rise in northern India so there is need to educate the patients regarding risk factor modification and importance of early intervention to prevent future progression of peripheral vascular disease.

Prevalence of Thyroid disorders in Patients of type 2 Diabetes Mellitus.

Background: Diabetes has become a major health challenge worldwide. Various studies have found that diabetes and thyroid disorders mutually influence each other and both disorders tend to coexist. Objective: To find out the prevalence of thyroid disorders in patients of type 2 diabetes mellitus. Material and methods: The study was conducted on 200 patients of type 2 diabetes mellitus aged between 40-70 years. All the patients were evaluated for thyroid dysfunction by testing thyroid profile (T3, T4 & TSH). The correlation of prevalence of thyroid disorder with gender distribution, age distribution, HbA1C, duration of diabetes, hypertension, family history of thyroid disorder, BMI, usage of OHA’s and insulin and dyslipidemia was then done. The observations and interpretations were recorded and results obtained were statistically analyzed. Results: There was a high prevalence (16%) of thyroid disorders in patients of type 2 diabetes mellitus, most common was subclinical hypothyroidism (7.5%) which was further found to be more in females, elderly patients, patients with uncontrolled diabetes i.e. HbA1C values ≥7 or patients on insulin and patients with BMI >30. Conclusions: Screening of thyroid dysfunction should be done in all diabetic patients especially in patients with poor diabetic control.

Concurrent infection of pneumocystis pneumonia and pulmonary tuberculosis in an HIV-seronegative patient.

Co-infection with Pneumocystis jirovecii and Mycobacterium tuberculosis is rarely reported in patients without human immunodeficiency virus (HIV) infection. We describe the case of a 33-year-old HIV-negative female patient who was on long-term oral corticosteroids for rheumatoid arthritis and admitted with for respiratory distress and diffuse infiltrative pneumopathy in whom concurrent infection with Mycobacterium tuberculosis and Pneumocystis jiroveci was confirmed by bronchoalveolar lavage (BAL) fluid examination.

Experimental study of oculocardiac reflex (OCR) with graded stimuli.

The present study was conducted to observe the effect of graded mechanical stimuli on occurrence of oculocardiac reflex (OCR). The experiments were carried out in twenty albino rabbits of either sex weighing between 1-2 kg. Changes in heart rate and/or cardiac rhythm (oculocardiac reflex) were studied by applying traction with progressively increasing weights to medial rectus muscle. Mean threshold value of square wave mechanical stimulus just sufficient to produce oculocardiac reflex was found to be 19 +/- 8.52 g. As the traction weights were progressively increased, more and more decrease in heart rate was observed. It was concluded that once the threshold value of stimulus was reached, the oculocardiac reflex showed a graded response with progressively increasing traction weights.

Profile of lower gastrointestinal bleeding in children from a tropical country.

Eighty five children were evaluated endoscopically for recurrent lower gastrointestinal (GI) bleeding. The male: female ratio was 2.4:1 with a mean age of 6 years (range 8 months to 2 years). After adequate bowel preparation endoscopic evaluation was done using olympus CF 101 colonoscope. Sedation was given only in two patients. Full length colonoscopy had been done in 16 cases only, to look for extent of disease in 8 cases and to ascertain site of bleeding when no lesion could be seen on sigmoidoscopy. Juvenile polyps were seen in 40 cases, amoebic ulcer in 20, solitary rectal ulcer in 4 and polyposis syndrome in 5 cases. Sigmoidoscopy alone could establish the diagnose in 76 cases. We conclude that flexible sigmoidoscopy alone is safe and adequate in ascertaining the cause of prolonged recurrent lower GI bleeding.

Management of foreign bodies of the upper gastrointestinal tract.

The use of flexible endoscopes had made removal of foreign bodies in the upper gastrointestinal tract easier and safer. We describe our experience of 49 cases of foreign bodies of the upper gastrointestinal tract. Majority (67%) of the patients were children and only 4 patients (8%) were above 45 years of age. The most common foreign bodies encountered were coins (25), fruit stones (4) and dentures (3). In 29 patients foreign bodies were lodged in the oesophagus and in 15 cases in the stomach. Forty one patients were considered for endoscopic removal of the foreign bodies and 40 could be managed successfully. There were no procedure related complications. We conclude that endoscopic removal of the foreign bodies of the upper gastrointestinal tract is a safe and effective technique.

Sonographic renal length in Indian children.

For the purpose of making norms of ultrasonographic renal length in Indian children, 240 children (137 boys and 103 girls) below 5 years of age were subjected to sonographic evaluation in supine position. Left renal length increased from 59.18 mm, in infancy to 81.89 mm between 4-5 years age in female children. Similar increase was observed in male children. There was no statistically significant difference in renal length in boys and girls in various age groups (p 0.05 to 0.1). Right renal length measured 1-3.5 mm than less than the left renal length, and this difference was statistically significant (p 0.05 to 0.0002) in both sexes. Renal length positively correlated to subject's age, length/height, body weight and body surface area in that order.

A clinico-investigative profile in Graves' ophthalmopathy.

A clinico-investigative profile was studied in 30 patients with Graves' Ophthalmopathy (GO) (15 each with early and late). In accordance to the thyroid status 63.3% of patients were hyperthyroid and 36.7% euthyroid. There was slight female preponderence, with ratio being 1.5:1. Exophthalmometric readings were significantly high in GO patients as compared to controls. However, no significant diagnostic role of postural exophthalmometry was seen. Positional tonometery may have respectable place among the tests for early diagnosis of GO; however, it could not differentiate between hyperthyroid and euthyroid cases. Further the role of ultrasonography, if available could not be overemphasized.

Bilateral proptosis due to metastatic Ewing's sarcoma of the orbit: fine needle aspiration cytology (FNAC) and histopathology of a case.

Bilateral proptosis due to metastatic Ewing's sarcoma is an extremely rare presentation and thus merits reporting. The role of fine needle aspiration cytology in the diagnosis is highlighted.