Spontaneous rupture of a congenital umbilical hernia in an infant: a rare complication.

Umbilical hernia is not uncommon in children. Most of these hernias close spontaneously as the children grows; they are often remarkably free from complications. Though in no way affecting the accepted principles of management of umbilical hernia, we feel that this case of spontaneous rupture is worth recording. To report a case of spontaneous rupture of a congenital umbilical hernia with evisceration of small intestines in a 45-day-old 3.5 kg female infant.

Transoral migration of peritoneal end of ventriculoperitoneal shunt with perforation of gastro-esophageal junction: a case report of a rare complication.

A rare complication of ventriculoperitoneal (VP) shunt is presented. A 11-year old boy presented with a tube coming out of the mouth. He had multiple VP shunt done earlier. Clinical features, laboratory investigations and imaging studies showed that the peritoneal end had perforated the gastro-oesophageal junction and then prolapsed trans-orally. The shunt was removed and he made an uneventful recovery. Though migration of the peritoneal end of the shunt tube into various organs is known, to our knowledge, only six/seven cases have been reported in the English literature of a shunt tube coming out of the mouth and this is the next. The management of this very rare problem is discussed.

Therapeutic drug monitoring of antiepileptic drugs.

Commonly used conventional antiepileptic drugs for pharmacotherapy in epilepsy are phenytoin, carbamazepine and valproic acid. These drugs have complex pharmacokinetic properties leading to fluctuation in their plasma level at given same therapeutic dose. The present study was done to monitor their plasma levels. A prospective observational study was conducted at National Public Health Laboratory. After taking detail history, blood samples were taken from epileptic patients of all age groups and both gender who were on usual therapeutic dose of one or two combined antiepileptic drugs. Plasma level of these drugs were analyzed by using Fluorescence Polarization Immuno Assay (FPIA) technique. Out of total 417 testing, 81 were tested for phenytoin , 241 for carbamazepine and 95 for valproic acid. Their levels were further analyzed to find therapeutic, subtherapeutic and toxic levels. Out of total 81 blood samples tested for phenytoin, 38.8% had plasma drug at therapeutic level, 38.8% at subtherapeutic level and 28.4% had toxic level. Carbamazepine was tested in 241 samples and 79.3% cases had at therapeutic drug level, 15.8% had subtherapeutic drug level and 4.9% had toxic level. Out of 95 samples tested for valproic acid, 62% had therapeutic level and 20% had subtherapeutic and 18% had toxic level of drug. Therapeutic drug monitoring of phenytoin showed wide fluctuation in its plasma level. Its toxic and subtherapeutic levels were quite high. It is suggested that the dose of phenytoin should be adjusted after regular plasma level monitoring only. Monitoring of carbamazepine and valproic acid were also helpful when their toxicity and efficacy are doubtful.

Study on CD4 cell responses in HIV infected subjects in Nepal.

HIV infection is characterized by gradual deterioration of immune function mainly the CD4 cells. This study was conducted with the objectives to evaluate the kinetics of CD4 cell depletion and duration of HIV infection and the role of ART in improving CD4 cell levels specifically in Nepalese HIV patients. During April 2005 to March 2006, all together 220 blood samples collected from 110 HIV patients visiting National Public Health Laboratory (NPHL), Kathmandu, were analyzed for CD4 cell count using standard protocol. CD4 cell count before and after starting of anti-retro viral therapy showed significant association (P<0.05). The results of this study clearly indicated that antiretroviral therapy has been playing a role in maintenance CD4 cell counts in HIV infected patients.

Shigella isolates of Nepal: changes in the incidence of shigella subgroups and trends of antimicrobial susceptibility pattern.

OBJECTIVES: Shigellosis is an important cause of bloody diarrhoea in all age groups, especially in children. A retrospective study was done to analyse the pattern of shigella isolates and the antimicrobial susceptibility trend of these shigella isolated at different hospitals of Nepal from Jan, 2003- Dec, 2005. MATERIALS AND METHODS: A total of 118 Shigella species isolated at nine different hospital laboratories of Nepal were reported to National Public Health Laboratory during January, 2003- December 2005 .The isolates were tested for the confirmation of identification and antimicrobial susceptibility pattern by standard bacteriological techniques. RESULTS: Of the 118 Shigella isolates reported, Shigella flexneri 51 (43.22%) was the predominant of the four species followed by Shigella dysenteriae 49(41.52 %) , Shigella boydii (7.62%) and Shigella sonnei (7.62%).But the yearly distribution of the Shigella isolates in 2003 and 2004 showed that Shigella dysenteriae was the most common of the four species. In 2005, a shift in the species was noted as Sh flexneri replaced Sh dysenteriae and became the most prevalent species. The percentage of Shigella dysenteriae type-1 among all Shigella dysenteriae were 66.66 % in 2003, 44.44 % in 2004 and 60 % in 2005. Individual or multiple resistances to Ampicillin, Nalidixic acid, and/or Cotrimoxazole was seen in all the four species of Shigella. 33% of the total Shigella isolates reported were multi drug resistant (showing resistance to 3 or more antibiotics at a time). Shigella dysenteriae type-1(Sd 1) isolates resistant to ciprofloxacin were also encountered in the present study .Of the total 25 Shigella dysenteriae type 1 isolates reported, 18(72%) were ciprofloxacin resistant . All the Shigella isolates were however sensitive to Ceftriaxone and Azithromycin. CONCLUSION: Distribution of different species of Shigella and their antibiotic susceptibility profile may vary from one geographical location to another and may also change with time. Systematic monitoring of the species and serotypes of Shigellae and their antimicrobial susceptibility can help to guide therapy and reveal periodic epidemics due to Sd 1, which may have acquired resistance to antibiotics that have previously been effective. Key words: Dysentery, Shigella, Shigella dysenteriae type-1, Antimicrobial resistance.

Epidemiology of typhoid and paratyphoid fever in Kathmandu: two years study and trends of antimicrobial resistance.

Enteric fever is prevalent in developing countries including Nepal, where it still remains as a major health problem. Appropriate antibiotics are essential for the treatment of typhoid and paratyphoid fever. A prospective study was carried out to characterize the epidemiological features of enteric fever in Kathmandu, Nepal and to analyse the recent trend of antimicrobial resistance pattern of the Salmonella isolated from the cases of enteric fever from different hospitals in Kathmandu during June, 2002 to June, 2004. A total of 1469 Salmonella typhi and Salmonella paratyphi 'A' isolates collected during this period from five different hospital laboratories situated in Kathmandu were studied. The antimicrobial susceptibilities of the isolates towards Ampicillin (10 mcg), Chloramphenicol (30 mcg), Cotrimoxazole (25 mcg), Ciprofloxacin (5 mcg) and Ceftriaxone (5 mcg) were determined by standard disc diffusion technique and Agar dilution technique were used to determine the minimum inhibitory concentration (MIC) for Ampicillin, Ciprofloxacin, Chloramphenicol and Ceftriaxone. All the isolates tested were found to be sensitive to Ceftriaxone and Ciprofloxacin, the most commonly used antibiotic for treatment of enteric fever in Nepal. Of the total isolates studied, 15.5% from 2002, 8% from 2003 and 3.45% from 2004 were found to be multidrug resistant (exhibiting resistance towards Ampicillin, Chloramphenicol and Cotrimoxazole). Of the total multi drug resistant Salmonella isolates, 92% were Salmonella typhi. All the multidrug resistant isolates were also further tested for susceptibilities towards Tetracycline (30 mcg), Nalidixic acid (30 mcg), Streptomycin (10 units), Gentamycin (25 mcg), Azithromycin (15 mcg), Kanamycin (30 mcg), Neomycin (30 mcg). 50% of the multi drug resistant Salmonella typhi were also resistant to Tetracycline. Plasmid analysis revealed that all of the multidrug resistant Salmonella typhi isolates with Tetracycline resistance harbored a large molecular weight (147 Kb) plasmid.

Salient and co-morbid features in benign prostatic hyperplasia: a histopathological study of the prostate.

OBJECTIVES: To study the salient histological features of prostatic tissues in relation to age and to analyse the co-morbid histopathological changes in benign prostatic hyperplasia. (BPH). DESIGN: Prospective study. SETTING: Histopathology unit of a busy clinical pathological laboratory in Kathmandu Metropolitan City. SUBJECTS: 106 prostatic biopsy specimens from patients diagnosed as BPH received for histopathological examination during 2001-2. MAIN OUTCOME MEASURES: Prominent histological features observed in prostatic biopsy specimens obtained from patients of various age groups and frequency of co-morbid histopathological changes in benign prostatic hyperplasia. RESULTS: Prominent histological features. All (106) specimens included in the series had BPH showing glandulostromal proliferation of which 4 cases (3.77%) (all aged below 70 years) showed predominantly stromal pattern. Corpora amylacea present in 25% (in 5th decade) increased in frequency to 100% (8th decade onwards) in the later years. Cystically dilated glands also showed age correlated increase (through 5th to 8th decade) from 50% to 100%. Other prominent features observed with an overall decreasing frequency in all age groups (taken together) were glands showing papillary infoldings (44.33%), lymphocytic collection/infiltration (31.13%), proteinaceous material (7.54%), calcification (6.60%), homogenous eosinophilic material (2.83%), and glands showing necrotic cells (1.88%).Of all these, corpora amylacea, proteinaceous material, cystically dilated glands and glands showing papillary infoldings were present in all cases beyond 7th decade. Co-morbid histopathological changes of BPH. Twenty six specimens (24.52%) showed co-morbid features in association with BPH which included inflammatory (16.98%) and neoplastic (7.54%). Acute prostatitis was observed in 2 cases (1.88%), chronic prostatitis in 16 cases (15.09%) and none showed features of both. Neoplastic changes( 8 cases) ranged from intraepithelial neoplasm (PIN) (2 cases), atypical glands (2 cases, both in 7th decade) to adenocarcinomatous changes (2 cases, one each in 6th and 7th decade) were also observed co-existent with BPH. Both PIN cases (1.88%) were grade PIN-2 and occurred one each in the 6th and 7th decade. CONCLUSION: Histological profiles of prostatic biopsy specimens were observed to correlate well with the senile changes of advancing age. A predominantly stromal proliferation was found in a relatively lower age group, while corpora amylacea and cystically dilated glands along with glandular proliferation heralded changes of senescence. Co-morbid histopathological features were associated with BPH in a quarter (24.52%) of cases. Prostatitis was twice as common as neoplastic changes. Adenocarcinomatous changes were observed (2 cases) incidentally. PIN was recorded in 1.88% of specimens examined. Peak frequency of prostatitis was noted in the 6th decade while 7 of 8 neoplastic changes occurred in those of 60-80 years.