lenalidomide induced toxic epidermal necrolysis and del [5q]: co-occurrence of rarities

Primary myelofibrosis [PMF] is a clonal, BCR-ABL1 negative myeloproliferative neoplasm characterised by splenomegaly, leukoerythroblastic peripheral blood picture and bone marrow fibrosis. Different cytogentic abnormalities are documented in PMF which have impact on clinical outcome and overall survival. Del 5q31 is documented in only 0.8% of PMF patients and is associated with poor outcome and increased risk of progression to acute leukemia. Anemia with del 5q responds frequently to lenalidomide treatment. We are reporting case of a middle-aged male who presented with constitutional symptoms, myelofibrosis; and calreticulin type 2 mutation was present. His cytogenetics showed del 5q positivity. He was started on lenalidomide but developed toxic epidermal necrolysis, resultantly lenalidomide was stopped. Skin eruptions are a known entity in patients with lenalidomide therapy; but to date, there is no reported case of lenalidomide induced toxic epidermal necrolysis [TEN] in patients with myelofibrosis

Haematological parameters in different African populations: an experience from united nations level 3 hospital

Objective: To evaluate hematological parameters in African population to estimate normal reference intervals for these tests

Study Design: Cross sectional observational study

Place and Duration of Study: Department of Pathology, United Nations level 3 hospital, Nyala, Darfur from 1st Mar to 30th Dec 2014

Material and Methods: There were 396 healthy African male and female volunteers selected between 18-65 years of age, belonging to different countries. Fresh whole blood was used to measure haemoglobin [Hb] concentration, haematocrit [Hct], total red blood cell [TRBC] count, mean corpuscular volume [MCV], mean corpuscular haemoglobin [MCH], mean corpuscular haemoglobin concentration [MCHC], platelet count, total leucocyte count [TLC] and differential white blood cells count. Data were analysed using SPSS version 19

Results: Mean Hb of study group was 13.81 +/- 1.99 g/dl. Mean TLC was 5.50 +/- 1.96 x 103/ul. Mean lymphocyte count was 2.58 +/- 0.95. Mean platelet count was 234 +/- 92 x103 /ul. Mean values for Hb Concentration, TRBC, Hct Ratio, MCV, MCH and MCHC were all higher for African Males than Females; this difference was statistically significant [p<0.05]

Conclusion: This multi-national African population based study confirms the variations in haematological parameters previously described in single nation African studies. The commonly observed variations in normal adults are low RBC indices, relative neutropenia and lymphocytosis

effect of adding body mass index [BMI] and neck circumference to Epworth sleepiness scale [ESS] for diagnosing obstructive sleep apnea hypopnea syndrome in sleep clinics

Objective: To study the effect of adding body mass index and neck circumference to Epworth Sleepiness Scale [ESS] for diagnosing obstructive sleep apnea hypopnea syndrome in sleep clinics

Study Design: Cross sectional validation study

Place and Duration of Study: Department of Pulmonology, Military Hospital Rawalpindi from 1st July 2013 to 01 September 2014

Material and Methods: The ESS and ESS plus body mass index [BMI] and neck circumference [NC] data was evaluated for 150 patients hospitalized in our hospital for polysomnographic evaluation of obstructive sleep apnea. Overnight polysomnography [PSG] was done for all patients and was considered the gold standard for diagnosis of OSA. ESS Scoring, BMI and NC data was done using pre-designated questionnaire. All the data was analyzed using SPSS version 19

Results: Age ranged from 18-74 years with mean age of the study group 53 [ +/- 12.1 SD] years. Out of study population 87 [58%] were males and 63 [42%] females. In study population 80 [55.3%] patients had ESS >10. while 102 patients had ESS>10 with BMI > 35 kg/m2 and NC>40 cm. Using an AHI >/= 5 for OSA, 136 patients [90.6%] had OSA. Sensitivity of ESS > 10 for OSA was 55.15% but increased to 72.79% when BMI > 35 kg/m2 and NC > 40 cm was added to patients with ESS > 10. Similarly specificity and predictive values of study population for diagnosing OSA also increased after adding BMI and NC to ESS

Conclusions: In this study adding body mass index [BMI] and NC to ESS score significantly increased the sensitivity and specificity and positive predictive value for diagnosis of OSA

Frequency of hbv infection and its risk factors in asymptomatic military personnels

Objective: To determine the frequency of silent Hepatitis B virus [HBV] infection, its symptoms and risk factors in apparently healthy military personnel of Pakistan Army

Study Design: Descriptive cross sectional study

Place and Duration of Study: Department of medicine, Combined Military Hospital Okara from Oct 2012 to Mar 2013

Material and Methods: A total of 6236 healthy troops with age ranging from 18 to 57 years without previous or present history of HBV infection were selected by consecutive sampling from Okara Garrison. Blood samples were subjected to rapid screening of HBV infection using immunochrom atographic [ICT] kits [Intec production, Inc] with sensitivity and specificity of 99.8% and 95 % respectively. All positive cases were confirmed by 4th generation ELISA and PCR for HBV DNA were also sent. All infected cases were given a questionnaire about different risk factors of HBV infection. Finally variables were defined qualitatively and quantitatively and frequency, percentage, mean [SD] were calculated. All the data was analyzed using SPSS version 19

Results: Age ranged from 18-57 years with mean age of the study group 27 [ +/- 7.2] years. Mean age among those with HBs Ag positive was 32 [ +/- 7.3] years. Frequency of HBV infection was 2.03% [127 participants out of 6236] whereas PCR for HBV DNA was positive in 51 out of 127 [40.1%]. Most common symptom was anorexia in 16 patients [12.6%] followed by fatigue and fever in 15 patients [11.8%] each. While 42 patients [33.1%] were asymptomatic. Dental procedures was found to be most frequent risk factor [25.9%] followed by previous history of surgery [21.2%]

Conclusion: Although pre induction screening of HBV infection is carried out in Pak Army still its prevalence is matched with that of general Pakistani population. Soldiers' education and immediate vaccination is recommended at time of induction to stop the spread of this dreadful disease in Pak army

Effect of pioglitazone on serum high density lipoprotein [HDL] levels of type-2 diabetics

Objective: To study effect of Pioglitazone on serum high density lipoprotein levels in patients with type 2 diabetes mellitus

Study Design: Single blind randomized controlled trial

Place and Duration of Study: Department of medicine, Combined Military Hospital Multan from 1[st] Feb 2011 to 30[th] July 2012

Material and Methods: A total of 276 already diagnosed patients of diabetes mellitus type 2 between age of 30-80 years, presenting to the outpatient department of Combined Military Hospital Multan were selected. Type 2 diabetic patients were allocated group A or B using random allocation. Base line blood sugar fasting [BSF], glycosylated hemoglobin [HbAlc], high density lipoprotein [HDL] levels were taken. Group A was treated with Pioglitazone along with other hypoglycemic agents while group B was treated with only hypoglycemic agents and multivitamin tablets were added as placebo.After 12 weeks of treatment, serum HDL levels were measured to analyze effect of pioglitazone on serum HDL levels

Results: Pioglitazone group showed significant improvement in the serum HDL levels from baseline HDL 46.38 + 6.44mmol/L to 49.80+ 5.86 mmol/L after 12 weeks of therapy, [p = 0.001]

Conclusion: Pioglitazone when used in combination with other oral hypoglycemic agents has a beneficial effect on the serum HDL levels of the diabetics

Changes in P-wave amplitude and axis after treatment of chronic obstructive pulmonary disease exacerbation

To compare the change in P-wave amplitude and axis before and after 24 hours of the treatment of chronic obstructive pulmonary disease exacerbation.Quasi-experimental study. Department of medicine, PNS Shifa Karachi from Dec-2010 to June-2011 [six months]. A total of 93 subjects were included in the study. Their pre-treatment and post treatment ECGs were evaluated by measuring P-wave amplitudes in leads II and aVF and P-wave axes were calculated. The differences in terms of changes in P-wave amplitude and axis were compared. Mean age of patients was 53.09 +/- 7.20 years. Before treatment P-wave amplitude in lead II was 2.36 +/- 0.34 mm and after treatment it was 1.73 +/- 0.29 mm [p < 0.001]. P-wave amplitude in lead aVF before treatment was 2.446 +/- 0.334 mm while after treatment it was 1.556 +/- 0.329 mm [p < 0.001]. P-wave axis before treatment was 72.67[degree] +/- 4.67[degree] and after 24 hours of treatment it was 63.75[degree] +/- 3.95[degree] [p < 0.001]. Sigruficant changes in terms of reduction of P-wave amplitude and left ward rotation of P-wave axis occur after effective treatment of acute exacerbation of COPD. These findings provide valuable objective evidence in evaluating patient's response to treatment and recommended to be used in clinical practice

Frequency of coronary artery disease [cad] risk factors in armed forces

To determine the frequency of risk factors of coronary artery disease [CAD] in apparently healthy soldiers of Pakistan Armed Forces. Cross sectional descriptive study. Department of medicine, CMH Okara from July 2012 to Dec 2012. The study included 2215 male currently serving soldiers in age range of 18 to 52 years by consecutive sampling. Relevant history, body mass index [BMI], waist circumference [WC] and blood pressure [BP] of each subject were recorded. BMI > 25 kg/m[2] and WC > 90 cm was considered obesity and abdominal obesity respectively. BP > 140/90 mmHg was defined as hypertension. All the participants of study underwent blood glucose fasting, blood glucose random, ECG recording, personality assessment and lipid profile. Risk estimation was done using Eric Brittain scoring system. In our study group 95.5% patients were having at least 1 risk factor of CAD, 54% were having 2 to 4 risk factors while 3.93% had > 4 risk factors. Risk estimation of CAD using Eric Brittain scoring system showed that a large proportion of study group had high probability of developing ischemic heart disease in next 6 years. A large proportion of our soldiers are harboring risk of CAD due to increase in frequency of 8 conventional CAD risk factors especially obesity

Metabolic syndrome in soldiers of armed forces

Objective: To determine frequency of metabolic syndrome and its components amongst soldiers of Armed Forces

Study Design: Descriptive cross sectional

Place and Duration of Study: Medical department, Okara CMH, October 2012to March 2013

Patients and Methods: Our study included 2187 male soldiers. Age ranged from 20 to 52 years. Detailed history and examination of all the participants was done. Body mass index [BMI], waist circumference [WC] and blood pressure [BP] of each subject were recorded. BMI > 25 kg/m[2] and WC > 90 cm was considered obesity and abdominal obesity respectively. BP > 130/85 mmHg defined as hypertension. Blood glucose fasting, HDL cholesterol and triglycerides levels were checked in all participants. SPSS version 16 was used to analyzethe data. p value of less than 0.05 was considered statistically significant

Results: In our study, 783 participants [35.8%] were found to have abdominal obesity.Overall 491 [22.5%] soldiers had metabolic syndrome out of which 438 [89%] were physically inactive. Frequency of metabolic syndrome was 31.7% [156 out of 491] in age group 20 to 36 years while 68.3%[335 out of 491] in 37 to 52 years of age. Hypertriglyceredemia was present in 504 [23%], low HDL cholesterol in 496[22.6%], hypertension in 210 [9.6%] and abnormal glycemic control in 197 subjects [9%]

Conclusion: A large number of Army soldiers are suffering from metabolic syndrome. Its frequency is increased with increasing age, weight and physical inactivity.Patientswith previous history of diabetes or hypertension were 4 times at risk of developing Metabolic Syndrome as compared to others

Prevalence of non alcoholic fatty liver disease in patients with metabolic syndrome

To determine frequency of Non Alcoholic fatty liver disease in patients with Metabolic Syndrome [MetS]. Cross sectional study. Department of medicine, CMH Okara, Jan 2013 to July 2013. We included 491 adult males, diagnosed with metabolic syndrome [MetS], presenting in outpatient department for routine review. MetS was diagnosed as per the International Diabetes Federation [IDF] proposed criteria of 2004. Detailed history and examination of each individual was done and data entered in pre designed performa. Brightness and posterior attenuation on ultrasound abdomen were considered indices for fatty liver disease in presence of elevated ALT, negative hepatitis serology and absence of alcohol intake. All the data was analyzed using SPSS version 16. p value of less than 0.05 was considered statistically significant. Out of 491 participants with MetS, 222 [45.2%] had fatty liver disease. Mean BMI in patients with metabolic syndrome was 26.1 [ +/- .89] and mean BMI in fatty liver patients was 27.3 [ +/- 0.67].Out of total 5 components of Mets, patients with fatty liver disease had 3.24 [ +/- 0.25] components, as compared to 2.1 [ +/- 0.34] in whole of study group. A large number of patients with metabolic syndrome have fatty liver disease. Fatty liver disease is more frequent in patients who are overweight and those having multiple risk factors of metabolic syndrome

Frequency of resistant hypertension in a hypertensive population

To determine the frequency of resistant hypertension in hypertensive population. Descriptive study. CMH Kohat, Pakistan from Aug 2010 to Dec 2010. One hundred and fifty patients were selected for the study. All had blood pressure > 140/90 mmHg despite use of 3 antihypertensive drugs including one diuretic. Once admitted, patients were given the same medicines in the doses which they were taking under DOT [direct observed therapy] programme executed by a nursing assistant to exclude non-compliance to treatment. All the data was analyzed using SPSS version 16. Out of total 150 patients, 96 [64%] patients were males and 54 [36%] were females. Male to female ratio was 1: 1.8. Mean age was 46.93 years [SD +/- 16.38]. Compliance of patients to anti hypertensive treatment was ensures by DOT. There was no step up treatment. Mean BMI was 25.95 kg/m[2] [SD +/- 2.38], patients 71.3% were overweight i.e. BMI > 25 kg/m[2]. Out of total 150 patients, 16 [10.7%] patients had resistant hypertension using the cut off value of BP >140/ 90 mmHg. A significant number of hypertensive patients are suffering from resistant hypertension. Such patients need further evaluation to rule out any genetic, secondary and life style/diet related cause

Sputum neutrophilia in severe persistent asthmatics

Objective: To determine the frequency of sputum neutrophilia in patients with severe persistent bronchial asthma. Study Design: A cross-sectional study. Place and Duration of Study: Department of Medicine, Military Hospital, Rawalpindi, from November 2009 to November 2010

Methodology: Cases of severe persistent bronchial asthma, aged between 12 and 40 years, were included. Sputum samples were collected by induction with hypertonic saline [4.5%]. All samples were centrifuged and differential neutrophil count was calculated. Data was analyzed using SPSS 11

Results: Out of 195 patients, there were 129 [66.2%] males and 66 [33.8%] females. The mean age was 27.01 +/- 6.92 years. Mean sputum neutrophilic count was 126.47 +/- 16.52 x 106/ml and the mean neutrophilic percentage was 63.187 +/- 8.3363. Sputum neutrophilia was present in 84 patients [43.1%], out of whom, 56 were males and 28 females. In patients with sputum neutrophilia, mean neutrophilic count was 142.40 +/- 8.49 x 106/ml and the mean neutrophilic percentage was 71.2024 +/- 4.2441%

Conclusion: Sputum neutrophilia is a frequent finding in cases with severe persistent bronchial asthma. Presence of sputum neutrophilia in such cases can lessen the inappropriate use of corticosteroids with their associated long-term side effects

Vitamin d deficiency in patients with tuberculosis

To determine the frequency and association of Vitamin D deficiency in patients with tuberculosis. Case control study. Medical Department, Combined Military Hospital, Kharian, from July 2010 to June 2012. One hundred and five outdoor patients of tuberculosis were selected with 255 gender matched controls. Tuberculosis was diagnosed by presence of acid fast bacilli in sputum smears, positive culture for Mycobacterium tuberculosis or demonstration of chronic caseating granulomatous inflammation in tissue specimens. Controls were drawn randomly from general population. Serum 25 hydroxyvitamin D [25 [OH] D3] levels < 25 ng/ml was considered Vitamin D deficiency. The results were analyzed on SPSS version 17. Mean Vitamin D levels were 23.23 +/- 6.81 ng/ml in cases, 29.27 +/- 8.89 ng/ml in controls [p < 0.0001]. Vitamin D deficiency was found in 57% of cases and 33% controls [p < 0.0001]. Mean Vitamin D levels were significantly lower in females with tuberculosis [20.84 ng/ml] as compared to males [25.03 ng/ml, p = 0.002]. Mean BMI in patients of tuberculosis with Vitamin D deficiency were 19.51 +/- 1.77 kg/m2 and in patients with normal Vitamin D were 21.65 +/- 1.79 kg/m2 [p < 0.0001]. Mean Vitamin D levels in patients with multi-drug resistant tuberculosis was lower to a mean of 15.41 +/- 4.67 ng/ml [p < 0.0001]. There is significant deficiency of Vitamin D in patients with tuberculosis as compared to controls. This deficiency is more pronounced in females, individuals with low BMI, extra pulmonary and MDR tuberculosis.

Hypomagnesemia; frequency in patients with type 2 diabetes mellitus

To determine frequency of Hypomagnesaemia in patients of type 2 diabetes mellitus in our population. Random selection of DM II patients from Outpatient Department CMH, Kharian.: Cross sectional study. Combined Military Hospital Kharian, Department of Medicine. January 2011 to December 2011. We selected outdoor patients of DM-2 from both gender between 40 to 70 yrs of age by random sampling. Those selected, were subjected to blood fasting and random glucose measurements as well as serum magnesium levels. Blood samples were collected using full aseptic measures and vtfthin one hour, samples were transported to Armed Forces institute of Pathology [AFIP] for analysis. Serum magnesium level estimation was done by timed endpoint method using calmagite dye. DXC 600 automated analyzer was used. The results were verified by Pathologist. The overall frequency of Hypomagnesemia was 32.2% [124 out of the 385 subjects] using the cutoff value of less than 0.6mmol/l for Hypomagnesaemia, whereas 67.8% [261 out of the 385 individual] had normal serum magnesium levels. Significant number of patients with type 2 diabetes mellitus suffers from Hypomagnesaemia. These patients have increased risk risk of poor Glycemic control and diabetic complications due to Hypomagnesemia. Therefore, it is recommended that serum magnesium levels should be checked regularly in patients with type 2 diabetes mellitus and oral magnesium replacement should be done

Frequency of inter-atrial blocks in patients with ischemic stroke

To determine the frequency and association of Interatrial block in hospitalized patients with Ischemic Stroke. A case control study. Department of medicine, Military Hospital, Rawalpindi from 1st Jan 2009 to 30 December 2009. It included 64 patients, 32 cases of diagnosed ischemic stroke and 32 patients were taken as controls not suffering from ischemic stroke or ischemic heart disease. ECG findings of both selected groups were evaluated for presence or absence of interatrial block. Out of 32 ischemic stroke patients, 14 [43.85%] were found to have interatrial block on electrocardiogram [ECG]. Whereas only 6 [18.80%] controls were found to have interatrial block on ECG. Odds ratio was 1.66. Interatrial block is more frequent in ischemic stroke patients and may represent a risk factor for such stroke.

Type 2 diabetes mellitus; determination of frequency and pattern of hypertension in patients

Determine frequency of hypertension in type 2 diabetics. Determine pattern of hypertension in type 2 diabetics. Cross sectional survey. The study was conducted in the out patient department of Combined Military Hospital, Lahore. Study was carried out over a period of 01 year from July 2010 to July 2011. Total 700 cases were recruited in this study. Blood pressure of all the patients was recorded in a sitting position with a mercurial sphygmomanometer4-6 hours apart. It was interpreted as prehypertension, stage 1 and stage 2 according to operational definitions. Out of total 700 patients, 490 [70.0%] were hypertensive Pattern of hypertension showed 100 [20.4%] pre-hypertension, 160 [32.6%] stage-l and 230 [47.0%] stage-ll .Majority of the patients i.e. 245 [50.0%] were between 41-50 years and minimum 9 patients [1.8%] were 20-30 years old with mean age of 55.9_3.7 .Out of 700 patients, 350 [50.0%] were male while remaining 350 [50.0%] were females. Married patients were 400 [57.1%] and unmarried 300 [42.9%]. Patients with diabetes mellitus have increased risk of developing hypertension than normal population

Wheat pill: clinical characterisitcs and outcome

To determine the clinical characteristics and outcome in patients presenting with wheat pill poisoning. Retrospective study. Department of medicine, Combined Military Hospital, Kharian from 1st July 2009 to 30 December 2010. Fifty two patients with wheat pill ingestion were included in the study. All patients' history, symptoms, signs and management data was collected on a pre-designed data collection form. Mean age was 25.10 +/- 5.35 years with 51.9% females. Time interval between ingestion of pills and presentation to hospital was 2.5 +/- 1.27 hours. Numbers of pills consumed were 2.73 +/- 20. Most common symptom seen in patients was vomiting seen in 88.5% of the patients. Other common symptoms were irritability in 63.5% and confusion in 55.8% patients. Most common clinical sign hypoxia in 75% patients. Overall mortality was 86.5 percent. Wheat pills are highly toxic with rapid and high mortality rate. These patients develop refractory hypotension and metabolic acidosis which progresses to death. More research is required to develop antidote and to minimize toxicity. Strict legislations are required to control sale of aluminium phosphide over the counter

Tuberculous splenic abscesses in an immunocompetent patient

A 39 years old presented with low grade off and on fever and pain in the left upper abdominal region for one month. There was no history of cough, altered bowel habits, weight loss or contact with a case of tuberculosis. The patient was a nonsmoker. He was afebrile, with tenderness on deep palpation in left hypochondrium, spleen was not palpable. There was no palpable lymphadenopathy or jaundice. Laboratory investigations revealed raised 74 mm1hr ESR. Montoux test [1-TU PPD] was positive after 48 hours. Sputum smear was negative. Ultrasonography abdomen revealed normal sized spleen with multiple hypo echoic areas of various sizes, the largest measuring 2.8 x 3.6 cm. CT scan of the abdomen showed multiple small focal hypo dense lesions, suggestive of abscesses. CT-guided FNAC of the splenic lesions yielded frank pus. Smears showed epithelial cell granulomas, Langhan`s giant cells and few lymphoid cells with a necrotic background. Ziehl-Neelson stain revealed AFB. Mycobacterial culture and sensitivity testing of the pus that was aspirated showed a growth of M. tuberculosis after six weeks and the isolate was sensitive to first line of anti-Tuberculous drugs. The patient was found to be HIV negative by ELISA [Enzyme linked immunosorbent assay]. He was diagnosed to have Tuberculous multiple splenic abscesses