Organophosphorus poisoning.

Acute poisoning by organophosphorus (OP) compounds is a major global clinical problem, with thousands of deaths occurring every year. Most of these pesticide poisoning and subsequent deaths occur in developing countries following a deliberate self ingestion of the poison. Metacid (Methyl parathion) and Nuvan (Dichlorovos) are commonly ingested OP pesticides; Dimethoate, Profenofos, and Chlorpyrifos are other less frequently ingested compounds in Nepal. The toxicity of these OP pesticides is due to the irreversible inhibition of acetylcholinesterase (AChE) enzyme leading to accumulation of acetylcholine and subsequent over-activation of cholinergic receptors in various parts of the body. Acutely, these patients present with cholinergic crisis; intermediate syndrome and delayed polyneuropathy are other sequel of this form of poisoning. The diagnosis depends on the history of exposure to these pesticides, characteristic manifestations of toxicity and improvements of the signs and symptoms after administration of atropine. The supportive treatment of OP poisoning includes the same basic principles of management of any acutely poisoned patient i.e., rapid initial management of airways, breathing, and circulation. Gastric lavage and activated charcoal are routinely used decontamination procedures, but their value has not been conclusively proven in this poisoning. Atropine is the mainstay of therapy, and can reverse the life threatening features of this acute poisoning. However, there are no clear cut guidelines on the dose and duration of atropine therapy in OP poisoning. Cholinesterase reactivators, by regenerating AChE, can reverse both the nicotinic and muscarinic effects; however, this benefit has not been translated well in clinical trials. All these facts highlight that there are many unanswered questions and controversies in the management of OP poisoning and there is an urgent need for research on this aspect of this common and deadly poisoning.

Relapsing polychondritis: a rare disease of multisystem involvement.

Relapsing Polychondritis (RP) is a rare connective tissue disease of unclear pathogenesis and may present with multisystem involvement. In this report we describe a case of Relapsing Polychondritis, a rare autoimmune disease of varied presentation, course, and response to therapy.

Twelve episodes of meningitis in the same patient!

Recurrent bacterial meningitis is potentially life-threatening; resultant complications and adverse events during management take their extra toll on the patient. A rare case with 12 consecutive episodes of pyogenic meningitis, probably the maximum number ever reported in the literature, has been presented. A minor head injury but with no subsequent cerebrospinal fluid (CSF) leak during childhood was the index event in this patient. High resolution computerized tomography (HRCT) scan of the base of the skull clearly revealed a bony dehiscence missed on numerous previous imagings. Culprit micro organisms involved in recurrence were Streptococcus pneumoniae and Neisseriae meningitides. Though surgical repair would have been definitive treatment, medical management with pneumococcal and meningococcal vaccination and prophylactic penicillin have been used in this patient to prevent further recurrences.

Hemidiaphragmatic paralysis: a rare complication of cervical herpes zoster.

Herpes zoster, a sequel of the reactivation of the varicella zoster virus, usually presents with cutaneous eruptions associated with intense pain and burning sensation in the affected dermatomes. Motor weakness, however, can sometimes complicate herpes zoster. In this report we present a case that had diaphragmatic motor weakness as a sequel of herpes zoster lesions in the neck.

Poisoning : pattern and profile of admitted cases in a hospital in central Nepal.

An analysis of all poisoning cases admitted in medical and pediatric wards of Patan Hospital for one year (1st Jan to 31st Dec 2004) was carried out. A total of 154 cases were admitted which was 0.8% of total hospital admissions. Females outnumbered males and almost two-thirds patients were young adults (15-34 years). Seasonal variation in poisoning was observed with more cases in the summer months. Organophosphorus compounds (42%), drugs (25%), and zinc phosphide (6.5%) were common poisonings in total and in adult populations, whereas kerosene was the most frequent poisoning in pediatric age group. Paracetamol, benzodiazepines, and tricyclic antidepressants were the most frequently used drugs. The circumstances of poisoning were intentional (75%) and accidental (20%); most of the childhood poisonings were accidental in nature. The mean hospital stay for all type of poisoning was 7.5 days; whereas it was 10.2 days for organophosphorus, 2.5 days for paracetamol, and 1.5 days each for zinc phosphide and kerosene ingestion. Intensive care unit (ICU) service was required in 17% of patients; and almost 25% developed complications. Aspiration pneumonia and respiratory failure were the most frequently observed complications. Ninety four percent of admitted patients recovered completely; leaving a mortality rate of 5%.

Paroxysmal nocturnal hemoglobinuria.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disorder of acquired origin and is clinically manifested by chronic hemolysis, thromboses in various sites, and bone marrow failure. The disease is so rare that the delay in the diagnosis is not uncommon and this bears a tremendous impact on patient management. We present this case to draw attention to this uncommon cause of hemolytic anemia, which should be considered in any patient, of any age, who has signs of chronic hemolysis.

Delayed presentation of Sheehan's syndrome: a case report.

Sheehan's syndrome, though rare, is still one of the commonest causes of hypopituitarism in developing countries like ours. The clinical presentation is variable with abrupt or insidiously developing pituitary insufficiency after a heavy intrapartum or postpartum haemorrhage. We present an elderly lady with this syndrome who had slowly progressive panhypopituitarism 24 years after a severe haemorrhage associated with the delivery of triplets.