Neuroleptic Malignant Syndrome (NMS) after Treatment with Metoclopramide - A Rare Case Report

Neuroleptic Malignant Syndrome (NMS) is a medical emergency. It presents with mental status change, rigidity, fever, and autonomic dysfunction. It is caused by antipsychotics especially neuroleptic agents and certain antiemetic drugs like metoclopramide that block central dopamine pathways. We present a case of a 32-year-old male chronic alcoholic who presented to us with alcohol withdrawal symptoms and was given injection metoclopramide and developed neuroleptic malignant syndrome (NMS).Incidence rates for NMS range from 0.02 to 3 percent in patients treated with antipsychotic agents.1,2 Though it is commonly encountered in young adults, any age group can be affected.3,4 Males are two-fold more affected than females.4Metoclopramide, a commonly used anti-emetic agent has anti-dopaminergic properties and can give rise to development of NMS. The signs and symptoms of NMS include hyperthermia, altered mental status, muscular rigidity resembling extrapyramidal rigidity, autonomic instability, diaphoresis, hyper salivation, dysphagia, tachycardia, hypertension. NMS if left untreated, is usually fatal. So, early recognition and treatment is of great importance.

Atrial Fibrillation Presenting with Acute Abdomen in an Elderly Patient - A Case Report

A 63 years old male patient was admitted with complaints of acute pain in abdomen and nausea since 1 day. He had no history of chest pain, palpitations, shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea. There was no history of constipation or obstipation, vomiting’s, haematuria, or oliguria. Patient had a past history of systemic hypertension, diabetes, IHD since last 8 years. He was non-smoker, non-alcoholic. On examination, he was mesomorphic, febrile, had pulse rate of 146 bpm, irregularly irregular, his blood pressure was 134 / 86 mmHg. He had bilateral pitting oedema feet and on abdominal examination, there was diffuse tenderness in all the quadrants of abdomen. Guarding or rigidity over the abdomen was absent.ECG was suggestive of atrial fibrillation with fast ventricular rate as shown in figure 1. Haemoglobin 12.8 gm per dL, WBC - 24,900 cells / cumm, CKMB - 6, Troponin I was negative, serum cholesterol - 95 mg / dL, serum triglycerides - 91 mg / dL, LDL - 63 mg / dL, VLDL - 18 mg / dL, HDL - 14 mg / dL, serum LDH - 382 U / L, CRP - raised, D - dimer was positive, CHA2DS2 - VASC score was 4 and HAS - BLED score was 3. In view of persistent acute pain in abdomen, he underwent CECT abdomen which was suggestive of hepatosplenomegaly with hyper dense liver with multiple splenic and renal infarcts as shown in figure 2. 2D ECHO findings were dilated cardiomyopathy with congestive cardiac failure (ischemic) with 40 % left ventricular ejection fraction. He underwent coronary angiography, which revealed ischemic heart disease.

Subdural Haematoma (SDH) Leading to Subfalcine Herniation in a Case of End Stage Renal Disease

Subdural haematoma (SDH) is characterized by bleeding into the sub dural space surrounding the brain. It is mostly associated with atraumatic brain injury. It usually results from tears in bridging veins that cross the subdural space. ESRD is a risk factor for SDH. Coagulation abnormalities, volume overload, haemodialysis and platelet dysfunction predispose to SDH in ESRD and increase the morbidity and mortality.1 We report a case of a 44-year-old female, a known case of chronic kidney disease on maintenance haemodialysis who developed SDH with resulting subfalcine herniation.

In Search of an Ideal Obesity Assessment Tool : Is Body Mass Index Reliable Enough?

Obesity, a global pandemic, has become a chronic health problem within a modern western society. Obesity mimics the iceberg phenomenon wherein there is more to it than what we perceive resulting in various physical and psychological problems. Obesity is defined as surplus body weight for given height. . Obesity has been triggered by the growth of economy caused as an effect of industrialization, and urbanization, associated sedentary lifestyle, and transition of nutrition to canned foods. In the last few years, globally, countries have witnessed the spike in the rate of obesity. The endangering effects presented by obesity lead to numerous comorbidities that are being masked by the body dysmorphism. Metabolic disorders like diabetes mellitus type 2 and various cardiovascular risks hamper the regular metabolism of the body. Exploring the cascading effects in changing sedentary lifestyles draws many parallels to the surge in overweight and obesity among the people following such lifestyles. Increased adoption of sedentary lifestyles has resulted in a cascading effect on various metabolic disorders associated with obesity, globally. To address this surging concern, researchers around the globe have come up with multiple indices and parameters such as BMI, ABSI, VAI, BIA, DEXA, waist-hip ratio, and waist circumference, to quantify obesity in one final equation. However, these parameters have failed to give a conclusive summation that helps to identify the pre-symptoms of obesity. Similarly, variations in physical size and different body compositions for different weight categories usually pose tremendous challenges to quantify obesity. To make things more complicated various forms of obesity are being described and each has got its implication as far as the development of cardiovascular burden is concerned.This challenge presents the need to derive and identify a much robust, accurate and explicit index that would apply universally to all forms of obesity and would guide preventive and therapeutic strategies thereoff. In this article, an effort is being made to compare various parameters available globally to tail off the better and more reliable indicator available.

Acute Exacerbation of COPD Triggered by Pneumonia, and Secondary Spontaneous Pneumothorax (SSP).

Secondary Spontaneous Pneumothorax (SSP) can rarely complicate Chronic Obstructive Pulmonary Disease (COPD). Infections are common triggers for exacerbations of COPD. COPD with acute exacerbation presents with increasing dyspnoea. We present a rare case of a 75 year old female, who was a known case of COPD and developed right middle lobe pneumonia with partial collapse of the middle lobe along with a secondary spontaneous pneumothorax.

High-Sensitivity C-Reactive Protein in Metabolic Healthy Obesity (MHO)..

Metabolically Healthy Obesity/Metabolic Healthy Obesity (MHO) is a paradox in scientific medical literature and discussion is still on regarding the safety status of MHO phenotype. It is an obesity phenotype where the subjects have BMI more than or equal to 30 Kg/m2 but are devoid of conventional metabolic complications such deranged lipid profile, altered glucose tolerance, or metabolic syndrome as they have less adverse inflammatory profile, low visceral fat, less disturbed insulin signalling, and lipid metabolism. But recently studies are coming up with robust evidence that MHO is not a benign condition. It may lead to metabolic syndrome in future and it is also associated with cardiometabolic risks.METHODSThis cross-sectional study was done in a tertiary care hospital conducted for a period of two years from October 2017 to October 2019. After obtaining institutional ethical clearance, this cross-sectional study was conducted on 120 MHO subjects, 120 metabolic syndrome (MS) and 120 Metabolic Healthy Non-Obese (MHNO) subjects. Anthropometric data was obtained, and hs-CRP was estimated and compared with MS and MHNO group. The data was analysed using appropriate statistical significance tests.RESULTSIn one-way Analysis of Variance (ANOVA), anthropometric determinants and metabolic variables differed significantly across the groups (p<0.0001). The mean hs-CRP in MHO was; 4.45 ± 1.46 and in the control group it was 1.84 ± 0.77 (p<0.0001). Using Pearson’s correlation coefficient, significant positive correlation was found between hs-CRP with other anthropometric and metabolic parameters. In multiple regression analysis, Body Mass Index (BMI), Waist Circumference (WC), were significantly associated with elevated hs-CRP. Adjusted odd’s (AOR) of abnormal hs-CRP in MHO was 1.9 times that of MHNO subjects.CONCLUSIONSMHO phenotype is associated with increased hs-CRP levels as compared to MHNO phenotype suggesting that obesity even if associated with a healthy metabolic profile, still harbour subclinical inflammation. So, subjects with MHO should be targeted for appropriate preventive strategies in the form of health education, lifestyle alterations to avoid future cardiovascular morbidities. MHO phenotype with evidence of subclinical vascular inflammation should not be considered a benign condition.

Acute B Virus Hepatitis with Fulminant Hepatic Failure Precipitating Crisis in Sickle Cell Disease.

Sickle cell disease (SCD) is a hemoglobinopathy which involves multiple organs in the body. Hepatobiliary manifestations in SCD are many. Acute and chronic HBV infection may be transmitted through multiple blood transfusions in SCD. We report the case of a 36-year-old male with sickle cell disease who presented to us in acute liver failure and sickle cell crisis due to acute hepatitis B virus infection. Sickle cell disorder is a broad category under which all the patients who have a point mutation (haemoglobin S-HbS) on at least one Beta chain due to substitution of valine in place of glutamic acid at position 6 are included. Due to this substitution, HbS molecules have a sticky site allowing the molecules to aggregate. This aggregation worsens in deoxygenated state leading to the development of long polymers, sickling of erythrocytes and haemolysis. The most commonly affected site in SCD is the hepatobiliary system. The presentation due to this involvement varies from benign hyperbilirubinemia to a spectrum of manifestations termed “sickle cell hepatopathy”.1