Relevance of Anti-BmR1 IgG4 Antibodies in Children from an Area Endemic for Brugia malayi Infection in Kerala, India.

Brugian filariasis prevalent mostly in South-East Asian countries including India contributes to a small but significant proportion of the socioeconomic burden due to lymphatic filariasis. Along with bancroftian filariasis, brugian filariasis has been targeted for elimination globally. The lack of a reliable daytime diagnostic test has been seen as an important barrier to the successful implementation and monitoring of elimination programmes in brugia endemic areas. We evaluated an anti- BmRI-IgG4 antibody test namely, 'Brugia Rapid' in a large study meant to understand the clinical and pathological manifestations of brugian filariasis in children. We found the test superior to traditional night blood screening for microfilaraemia. Although an antibody detection test, we found it to be a reliable indicator of brugian infection. Among the 100 children studied extensively, 94% of the microfilaraemics, 86% of those showing filarial dance sign indicating presence of, live adult worms and 78% having abnormal lymphatics on lymphoscintigraphy were IgG4 positive. Coupled with its advantages like ease of use any time of the day, high sensitivity and specificity, this test may be the ideal tool to assist programme managers in their efforts to eliminate lymphatic filariasis where brugian infections are found.

Lymphoscintigraphic evidence of lymph vessel dilation in the limbs of children with Brugia malayi infection.

Lymphatic filariasis (LF) is targeted for global elimination by the year 2020. It was earlier believed that LF is mostly a disease of adults. Recent studies indicate that in endemic countries filarial infection starts mostly in childhood even though the disease manifestations occur much later in life. The initial damage to the lymph vessels where the adult worms are lodged is dilation, thought to be irreversible even with treatment. Most of these studies relate to bancroftian filariasis. Studies that address this early pathology in brugian filariasis in humans are scarce. We report here for the first time, the lymphatic abnormalities seen on lymphoscintigraphy (LSG) in children with Brugia malayi filariasis. LSG was performed in 100 children aged between 3-15 years, who were enrolled in the study either because they were microfilaremic; had present or past filarial disease or were positive for antifilarial IgG4 antibodies. Inguinal and axillary lymph nodes were imaged in most children. Dilated lymph vessels were visualized in 80 children and this pathology was evenly distributed in all the three study groups. Lymph vessels dilation was seen even in three year old children. The implications of these findings for management of LF and control programmes are discussed.

Carcinoma of the jejunum with multideposit peritoneal seeding, resection and intraperitoneal chemotherapy / Carcinoma del yeyuno con siembra peritoneal – depósito múltiple resección y quimioterapia intraperitoneal

Jejunal adenocarcinoma is rare, often presenting late with widespread intraperitoneal disease. Intraperitoneal chemotherapy (IPC) has been shown in non-randomized studies to improve the survival of patients presenting with intraperitoneal metastases from carcinoma of the colon, appendix and stomach and in primary peritoneal malignancies including mesothelioma and pseudomyxoma peritonei, providing that adequate operative cytoreduction can be performed. A case is presented of obstructive jejunal adenocarcinoma in which 19 intraperitoneal deposits were excised. The patient was treated successfully with immediate postoperative IPC followed by systemic chemotherapy. This condition is reviewed along with the rationale for IPC.

El adenocarcinoma del yeyuno es raro, presentándose a menudo de forma tardía con enfermedad intraperitoneal extensa. Estudios no randomizados han demostrado que la quimioterapia intraperitoneal (QIP) mejora la supervivencia de pacientes que presentan metástasis intraperitoneal del carcinoma de colon, apéndice y estómago, así como en malignidades peritoneales primarias, incluyendo el mesotelioma y el pseudomixoma peritoneal, siempre que se realice una adecuada citoreducción quirúrgica. Se presenta un caso de adenocarcinoma yeyunal obstructivo en el que se extirparon 19 depósitos del intraperitoneal, tratándose inmediatamente al paciente exitosamente con quimioterapia intraperitoneal postoperatoria, seguida de quimioterapia sistémica. Se examina esta condición junto con las razones para practicar la QIP.

A qualitative study on the feasibility and benefits of foot hygiene measures practiced by patients with brugian filariasis.

Disability alleviation is an important component of 'Global Programme for Elimination of Lymphatic Filariasis'. In Brugia malayi infection the disability is largely due to acute attacks of adenolymphangitis (ADL), which frequently prevent patients from attending their normal activities, causing much suffering and economic loss. The foot care programme has been shown to reduce the frequency and severity of these episodes. In the present study we used semi-structured interviews to evaluate the impact of the foot care in 127 patients with brugian filariasis. They were previously trained in this procedure and were advised to practice it regularly, unsupervised. All except one could recollect the various components of foot hygiene and were practicing it regularly. They were aware of the factors causing ADL attacks and were able to avoid them. Majority (95.2%) expressed their happiness with the relief provided by foot care, which prevented or reduced the ADL episodes. The motivation was such that they transmitted this knowledge to others suffering in the community and even physically helped them to carry out foot care. This study fully endorses the advocacy of foot care programme as an easy to carry out, effective, sustainable and economically feasible procedure to prevent acute ADL attacks.

Management of disability in lymphatic filariasis--an update.

The global lymphatic filariasis elimination programme incorporates disability management along with transmission control, to ensure 'a visible impact' on those who are already affected by the disease. The common manifestations of lymphatic filariasis like lymphoedema; elephantiasis and hydrocele result from irreversible damage caused to the lymphatics by the adult worms. Only palliative treatment in the form of physical methods and surgery is available for lymphoedema and elephantiasis. Hydrocele can be corrected by surgery. The most distressing aspect of lymphatic filariasis is the attacks of acute adenolymphangitis, which cause considerable short-term and also long-term disability by worsening the lymphoedema. Since each episode prevents the person from attending his work for several days, the economic loss is substantial. The precipitating cause of these attacks is secondary infection, the bacteria entering the tissues through 'entry lesions' in the skin. These episodes can very well be prevented by proper 'local-hygiene' of the affected limbs, which is a simple, effective, cheap and sustainable method that can be carried out even in the patient's house. These subjects and the providers of 'home care' should be trained in foot-hygiene programme, so that the message percolates to various levels in the affected communities, ultimately benefiting the patient.

Frosted retinal branch angiitis in an immunocompetent adult due to herpes simplex virus.

A case of acute severe loss of vision due to perivasculitis typical of frosted retinal branch angiitis due to Herpes simplex virus in an otherwise healthy young Omani lady is presented.

Estimation of ASO titer as an indicator of streptococcal infection precipitating acute adenolymphangitis in brugian lymphatic filariasis.

Recurrent episodes of acute adenolymphangitis (ADL) are important clinical manifestations of lymphatic filariasis which contribute significantly to the progression of lymphedema. It is increasingly being recognized that secondary bacterial infections play an important role in the etiology of ADL. We examined the role of streptococcal infection as a precipitating factor of ADL in brugian filariasis, by determining the anti-streptolysin O (ASO) titers and by isolating the causative organism wherever possible. The study population consisted of 30 patients with filariasis related ADL (Group A), 30 patients with chronic filarial edema (Group B) and 60 age and sex matched healthy adults (Group C). ASO titer was estimated by the latex agglutination method at the time of entry into the study, at the 15th day and at 3, 6 and 12 months. ASO titers were persistently elevated in 90% of patients in Group A and a portal of entry for bacterial infection was detected in all of these patients. In Group B only six patients had persistently elevated ASO titers. These patients had grade III lymphedema and three of them had monilial infections in the affected limb. In the control group none had persistently elevated ASO titers. The elevated ASO titers and the detection of a site of entry for bacteria in patients with ADL supports a streptococcal etiology for this condition.

Indications for penetrating keratoplasty in India.

Indications for penetrating keratoplasty (PK) in the developing world from a large series are not well documented. This study was done to evaluate the indications for PK in a major eye care institution in India. The records for a consecutive series of 1,964 PKs were analysed and multiple logistic regression was used to study the effect of age, socioeconomic status and sex on the indications for PK. The indications for PK were corneal scarring in 551 (28.1%) including adherent leukoma in 147 (7.5%), regrafts in 336 (17.1%), active infectious keratitis in 239 (12.2%), aphakic bullous keratopathy in 231 (11.8%), pseudophakic bullous keratopathy in 209 (10.6%), corneal dystrophies in 165 (8.4%) including Fuchs' dystrophy in 23 (1.2%), keratoconus in 118 (6%), and miscellaneous in 115 (5.9%). The odds that the patient belonged to lower socioeconomic status were significantly higher if the PK was done for active infectious keratitis (odds ratio 2.73, p < 0.0001), corneal scarring (odds ratio 1.72, p = 0.0009) or regraft (odds ratio 1.44, p = 0.047). Corneal scarring, including adherent leukoma, and active infectious keratitis are relatively more common indications whereas keratoconus, pseudophakic bullous keratopathy and Fuchs' dystrophy are less common indications for PK in India than reported from the developed world. Indications for PK which carry a poorer prognosis for graft survival are relatively more common in India than in the developed world.

Stomach as a conduit for esophagus--a study of 105 cases.

BACKGROUND: The stomach is a well known esophageal substitute. To analyze the mortality and morbidity following total laryngopharyngoesophagectomy (TLPE) with pharyngogastric anastamosis done as a single-stage procedure. METHODS: The technique employed was esophageal extraction by stripping method followed by gastric pull up. In 104 patients transportation of the stomach was done through posterior mediastinum and in one patient through presternal route. RESULTS: Significant post-operative complications included pharyngocutaneous fistula in 15 patients (14.3%) and pneumonitis in 20 patients (19%), Fifteen patients (14.3%) died due to the causes related to surgery. All patients who survived were able to swallow solid and liquid food, on an average of 14 days post-operatively. CONCLUSION: The stomach as a conduit following TLPE is a procedure which has given satisfying results when done in carefully selected patients.

Stomach as a conduit for esophagus--a study of 105 cases.

BACKGROUND: The stomach is a well known esophageal substitute. To analyze the mortality and morbidity following total laryngopharyngoesophagectomy (TLPE) with pharyngogastric anastamosis done as a single-stage procedure. METHOD: The technique employed was esophageal extraction by stripping method followed by gastric pull up. In 104 patients transposition of the stomach was done through posterior mediastinum and in one patient through presternal route. RESULTS: Significant post-operative complications included pharyngocutaneous fistula in 15 patients (14.3%) and pneumonitis in 20 patients (19%). Fifteen patients (14.3%) died due to the causes related to surgery. All patients who survived were able to swallow solid and liquid food, on an average of 14 days post-operatively. CONCLUSION: The stomach as a conduit following TLPE is procedure which givens satisfying results when done in carefully selected patients.

A preliminary study of filariasis related acute adenolymphangitis with special reference to precipitating factors and treatment modalities.

Episodic adenolymphangitis (ADL) is one of the important clinical manifestations of lymphatic filariasis. Recurrent ADLs contribute to the progress of the disease and also have important socioeconomic implications since they cause significant loss of man days. The present study was conducted in order to identify the precipitating factors responsible for ADL attacks and also to examine the different modalities of treatment. Sixty-five individuals with filariasis related ADL attacks, who are residents of Alleppey district (endemic for Brugia malayi) were studied. All efforts were taken to identify the precipitating factors for ADLs in these individuals. They were hospitalized for a period of five days or more. All of them received symptomatic antipyretic/antiinflammatory therapy and topical antibiotic/antifungal treatment of the affected limbs. They were then randomly allocated to one of the following four regimens: group I - symptomatic alone; group II - symptomatic plus antibiotics; group III - symptomatic followed by diethylcarbamazine citrate (DEC) and group IV - symptomatic plus antibiotic followed by DEC. Patients in groups III and IV received DEC every three months up to one year. There was a significant relationship between the number of ADL attacks and the grade of edema. Presence of focus of infection in the affected limb could be identified in 28 of the 65 patients. In the majority of patients (48) response to treatment was rapid (resolution in less than five days). Neither antibiotics nor DEC (given at intervals of three months) appeared to alter the frequency of ADL attacks. On the otherhand simple hygienic measures combined with good foot care and local antibiotic/antifungal cream application (where required), were effective in reducing the number of ADL attacks.