A case of anterior abdominal wall tuberculosis

A rare case of a middle-aged woman who presented to our emergency department with a huge swelling over lower part of abdomen for 3 years that was associated with continuous purulent foul-smelling discharge from multiple sites over swelling for past 2 years and all her past history was irrelevant except for her significant loss of weight for 6 months and unable to ambulate due to huge swelling for 6 months. She is known diabetes mellitus type 2 for 6 years on oral hypoglycemic drugs. On examination she had stable vital signs, mild pallor, a large globular swelling of about grossly 30×30×20 cm extending from 2 cm below umbilicus superiorly till pubic symphysis inferiorly, bilaterally extending till anterior superior iliac spine, flanks not full, multiple dilated veins over skin. Multiple foul smelling pus discharging sinuses, prominence on leg raise test and absent cough impulse, rest of the abdomen is soft and non-tender with no organomegaly and present bowel sounds. Bilateral inguinal group of lymph nodes were palpable and matted. Swelling was exclusive extra peritoneal on computed tomography (CT) scan. Excision of swelling was done up to anterior rectus raw area open wound with bilateral inguinal lymph node excision was under general anesthesia was done. Histopathology showed granuloma with caseating necrosis from lymph nodes. Anti-tuberculosis therapy intensive phase was started post operative wound was healthy, and after 6 weeks of initiation of anti-tubercular treatment wound was closed with secondary suturing.

Qualitative and quantitative assessment of Theileria annulata in cattle and buffaloes Polymerase Chain cattle and buffaloes Polymerase Chaincattle and buffaloes Polymerase Chain Reaction

Bovine tropical theileriosis caused by Theileria annulata is a tick-borne disease associated with high morbidity and mortality in the livestock. The conventional method of diagnosis is by the demonstration of the parasite stages by microscopic examination. This method suffers from low sensitivity, making it even more difficult to detect piroplasms in the carriers. PCR based assays are known to be more sensitive. The present study was undertaken to detect and quantify T. annulata in the blood of clinically infected and carrier animals using a quantitative PCR protocol targeting the gene encoding the major merozoite piroplasm surface antigen Tams 1. A total of 116 samples were collected from infected as well as apparently healthy cattle and buffaloes. Of these, 74 samples (63.79%) were positive for T. annulata by real-time PCR, including the 15 samples that were positive by Giemsa staining. The parasite load ranged from 1.39 x 106 to 3.35 x 109 and 0.35 x 106 to 2.83 x 107 ml-1 of blood in cattle and buffalo samples, respectively by qPCR. Our study suggests that real-time PCR assay can be used to detect and quantify the load of T. annulata in the blood of cattle and buffaloes. It also serves as a support to clinical diagnosis and assessment of carrier status in apparently healthy animals.

Nevirapine versus efavirenz based antiretroviral treatment in naive Indian patients: comparison of effectiveness in clinical cohort.

OBJECTIVE: Our objective was to compare immunologic effectiveness of nevirapine and efavirenz based antiretroviral therapy in antiretroviral naïve HIV-1 infected Indian patients. DESIGN AND METHODS: Study was an observational, non-randomized, longitudinal cohort. Antiretroviral naive HIV-1 infected patients receiving efavirenz + 2NRTI (n=254) and nevirapine + 2 NRTI (n=857) from April 2000 were followed up at two tertiary care HIV clinics at Ahmedabad and Pune. Patients were followed up clinically monthly and CD4 was carried out every 3 monthly. All patients were examined for various side effects as well as development of various OIs. Data were analyzed using standard statistical methods. RESULTS: Baseline characteristics for both the groups (NVP and EFV) were comparable. In the random effects model, there was an increase of 40.97 (p < 0.05) units of CD4 cell counts with an unit increase in time in the NVP arm as against a 44.75 (p < 0.05) units of increase in CD4 cell counts in the EFV group with a unit increase in time, which is significant for both groups. However, at any given point of time there was no difference in the rate of increase of CD4 count between the two treatment arms (p = 0.58). Hypersensitivity reaction (6.6% in NVP vs. 2.32% in EFV, p = 0.0146) and hepatitis (3.2% in NVP vs. 0% in EFV, p = 0.0085) were more common with nevirapine, while neurologic disturbances (0.93% in NVP vs. 20.15% in EFV, p = 0.0001) were more common with efavirenz. Incidence of distal sensory neuropathy and lipid abnormalities was similar in both the groups. CONCLUSION: Use of NVP and EFV based HAART in antiretroviral naive Indian patients led to significant and durable rise in CD4 cell count. Although observational and non-randomized, our study showed equivalent immunological response amongst NVP and EFV based HAART which is in line with the results of the 2NN study.

API consensus guidelines for use of antiretroviral therapy in adults (API-ART guidelines). Endorsed by the AIDS Society of India.

With rational use of antiretroviral therapy (ART), human immunodeficiency virus (HIV) infection has been transformed into a chronic manageable illness like diabetes and hypertension. These guidelines provide information on state of art, evidence based approach for use of ART in Indian context. When to initiate ART? Antiretroviral therapy is indicated for all symptomatic HIV infected persons regardless of CD4 counts and plasma viral load (PVL) levels. In asymptomatic patients, ART should be offered when the CD4 counts < 200/mm3 and should be considered in patients with CD4 counts between 200-250/mm3. Therapy is not recommended for patients with CD4 count more than 350/ mm3. Involvement of patient in all treatment decisions and assessing readiness is critical before initiating ART. What to start with? A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen is recommended for antiretroviral naïve patients. The choice between nevirapine and efavirenz is based on differences in adverse events profiles; cost and availability of convenient fixed dose combinations and need for concomitant use of rifampicin. A backbone of 2-nucleoside reverse transcriptase inhibitors (NRTIs) is combined with the NNRTI. Various combinations and ART strategies not to be used in clinical practice has been enlisted. How to follow up? Recommendations have been made for baseline evaluation and monitoring of patients on ART. These include guidelines on laboratory and clinical evaluation. A plasma viral load at 6 months after initiation of first-line ART is strongly recommended. Yearly estimation of lipid profile has been recommended. How to identify and manage ART failure? The guidelines recognize the issue of identifying ART failure late if only CD4 counts are used for monitoring. In the absence of resistance testing various second-line regimens have been enlisted. A boosted protease inhibitor based regimen is recommended in this situation to be combined with 2-NRTIs. Special situations Recommendations have been made for use of ART in HIV-TB, HIV-HBV, and HIV-HCV co-infected patients. In patients with active TB and a CD4 count < 200/mm3, initiation of ART is recommended as soon as the anti-TB treatment is tolerated. Efavirenz is the only ARV drug, which can be safely used with rifampicin. In pregnancy use of single dose nevirapine for reducing risk of mother to child transmission of HIV is not recommended, because of the risk of development of resistance. For post-exposure prophylaxis taking ART treatment history of the source patient is crucial in designing an effective regimen.

Lactic acidosis in HIV-I infected patients receiving antiretroviral therapy.

Highly active antiretroviral therapy (HAART) has resulted in dramatic declines in morbidity and mortality in HIV-I infected patients in the developed world. However, with the availability of generic antiretroviral treatments (ART) in India, a large number of patients now receive ART. Increase in experience with ART has led to the detection of drug-related toxicities. We report herein potentially fatal side effects associated with the use of nucleoside analogues in HIV treatment--hyperlactatemia and lactic acidosis/hepatic steatosis.

Capillaria hepatica, a parasite of zoonotic importance--a brief overview.

This review briefly elucidates the biology and mode of transmission of the parasite capillaria hepatica, an cuimial parasite. Occasional transmitted to man.

Medulloblastoma--a retrospective analysis.

A retrospective review of 45 patients was undertaken at the All India Institute of Medical Sciences to assess the outcome and prognostic factors for these patients who received post operative radiotherapy with or without chemotherapy for medulloblastoma. The median age at diagnosis was 11 years, with 34 males and 11 female patients. Thirty four tumours were confined to midline structures, and 11 were localised to one cerebellar hemisphere or involved midline and lateral structures. Complete macroscopic removal was achieved in 24 patients and subtotal removal in 21 patients. Forty one patients underwent craniospinal irradiation and 27 patients received adjuvant chemotherapy. Median overall and disease free survival was 57 and 31 months respectively and 3 year overall survival was 76%. The addition of adjuvant chemotherapy was a significant factor for disease free survival (p = 0.01) whereas extent of surgery (total vs subtotal, p = 0.01) was a significant factor for overall survival only. Eleven patients developed recurrent disease, with ten relapsing first in the posterior fossa.

Evaluation of transperineal template implant technique in Indian cervical carcinoma patients.

The prognosis in advanced cervical cancer patients is poor specially in presence of distorted anatomy, gross residual growth etc. In these cases template implant offers good option for treatment. We have carried out the procedure in 19 patients with acceptable level of complication. Preliminary results have been described.