Pure White Cell Aplasia Associated with Secondary Hemophagocytosis: Experience from the Indus Hospital

Pure white cell aplasia (PWCA), also known as agranulocytosis without granulopoiesis, is an uncommon condition that causes neutropenia. If linked with thymomas or medication-induced PWCA, surgical thymectomyor drug cessation may be therapeutically helpful. Here we present the case of an adult 18-year-old male came at The Indus Hospital and Health Network (IHHN) , Karachi in-patient department (IPD) with a complaint of colicky abdominal pain and loose stools for 10 days that were watery in consistency and large in amount, 6-7 episodes per day, for which he was taking flagyl. 5 days later, the patient developed high grade fever (102°F) with on and off chills that regressed on antipyretic. The patient also had decreased appetite and 2-3 episodes of vomiting. He had a history of dengue fever and Posterior Inferior Cerebellar Artery (PICA).Laboratory work-up revealed that he had been suffering from severe neutropenia. His bone marrow biopsy indicated absolute neutropenia with normocellular bone marrow demonstrating virtually total lack of myeloid progenitors, with maintenance of erythroid and megakaryocytic lineages, findings strongly indicative of PWCA with secondary hemophagocytosis. Findings of the case highlights the importance of an unusual clinical condition PWCA with hemophagocytosis. The aggressive clinical course of the idiopathic variant necessitates early immunosuppressive treatment.

CD8+ Mycosis Fungoides in Peripheral Blood; A Rare Finding

Cutaneous T cell lymphomas are mature lymphomas of T lymphocyte presenting with skin lesions and/or systemic manifestations. Majority of these cases show CD4+ phenotype and are classified as Mycosis Fungoides (MF)/Sezary syndrome (SS) spectrum.Here we present a case of 74-year-old male patient, having no known comorbid, presented in Dr. Ziauddin Hospital, Karachi OPD with complains of generalized skin lesions, itching for 2 years, generalized weakness for 4 months and no lymphadenopathy or visceromegaly. CBC showed absolute lymphocytosis and absolute eosinophilia. Some lymphocytes exhibited cerebriform nuclei. CT scan neck, chest and abdomen showed bilateral enlarged superficial inguinal lymph nodes and multiple enlarged bilateral axillary lymph nodes. Skin biopsy was inconclusive. Immunophenotyping of peripheral blood was then performed which showed an aberrant T cell population showing positivity for CD3, CD8, CD2, CD25 and negative for CD4, CD45, CD5, CD30, CD56 with variable expression of CD7. Case was finalized as CD8+ Mycosis Fungoides with peripheral blood involvement.These findings are very rare and highlight the importance of integrated approach to clinical course, morphological findings and other ancillary tests to be used in correlation with each other. These findings also highlight the diversity present in T cell malignancies in terms of immunophenotype.

Assessment of the Quality of Life among Diagnosed Hypertensive Patients Attending Primary Health Centers in Majmaah, Saudi Arabia

Introduction: Very few studies have been successful in assessing the health-related quality of life among diagnosed hypertensive patients attending clinics or hospitals for follow-ups. Since the Ministry of Health, Saudi Arabia has dedicated a separate webpage to tackle this problem; feedback through community-based studies is needed to ensure proper planning and implementation. Methodology: A community based cross-sectional study was done to find out the correlation between the quality of life and hypertensive patients undergoing treatment in Majmaah, Saudi Arabia. Results: A total of 184 participants with a mean age of 57.8 years completed this study. Female participants (26.8%) overwhelmingly rated their quality of life as excellent as compared to male participants (4.9%) even though an equal number of both participants (20.2%) considered it to be good. Conclusion: A longitudinal study is needed to find out this significant difference in the symptomatology of Saudi male and female hypertensive patients on long term medication.

Effect of organophasphate poisoning among patients reporting at a tertiary healthcare facility of Sindh Pakistan

Objective: To determine the effect of organophosphate poisoning [OPP] among patients at tertiary healthcare, Pakistan

Methods: This cohort study was conducted over a six-year period [January 2011 to December 2016] of OPP patients admitted to the intensive care unit of Peoples University of Medical and Health Sciences for Women SBA, Hospital Pakistan and their outcome was determined

Results: Total mortality was 17.39% [84 deaths in 483 patients, excluding those referred to Karachi]. Out of these 84 deaths, 65 patients [13.46%] expired due to cardiorespiratory failure, 17 deaths [3.52%] followed due to complication of mechanical ventilation and ICU acquired infection and two deaths [0.41%] occurred due to renal failure. The major cause of poisoning was deliberate self-harm /suicidal intention [93.02%], with gender distribution of female [57.07%] and male [35.95%], followed by unintentional/accidental exposure [6.98%] in males. The intensive supportive treatment, precise and appropriate respiratory care, and adequate amount of atropine and pralidoxime doses are keys to reducing the OPP patient's mortality

Conclusion: Organophosphate poisoning [OPP] intoxication is common in female gender. The easy availability of these harmful compounds has resulted in increased mortality either by accidental exposure or most often by the deliberate suicidal attempt

Targetome analysis revealed involvement of MiR-126 in neurotrophin signaling pathway: a possible role in prevention of glioma development

Objective: For the first time, we used molecular signaling pathway enrichment analysis to determine possible involvement of miR-126 and IRS-1 in neurotrophin pathway

Materials and Methods: In this prospective study, validated and predicted targets [targetome] of miR-126 were collected following searching miRtarbase [http://mirtarbase.mbc.nctu.edu.tw/] and miRWalk 2.0 databases, respectively. Then, approximate expression of miR-126 targeting in Glioma tissue was examined using UniGene database [http://www.ncbi. nlm.nih.gov/unigene]. In silico molecular pathway enrichment analysis was carried out by DAVID 6.7 database [http://david. abcc.ncifcrf.gov/] to explore which signaling pathway is related to miR-126 targeting and how miR-126 attributes to glioma development

Results: MiR-126 exerts a variety of functions in cancer pathogenesis via suppression of expression of target gene including PI3K, KRAS, EGFL7, IRS-1 and VEGF. Our bioinformatic studies implementing DAVID database, showed the involvement of miR-126 target genes in several signaling pathways including cancer pathogenesis, neurotrophin functions, Glioma formation, insulin function, focal adhesion production, chemokine synthesis and secretion and regulation of the actin cytoskeleton

Conclusion: Taken together, we concluded that miR-126 enhances the formation of glioma cancer stem cell probably via down regulation of IRS-1 in neurotrophin signaling pathway

Enterolithiasis: A Rare Finding in Intestinal Tuberculosis

Though intestinal tuberculosis is relatively a common ailment in India and other developing countries; enterolithiasis is a rarely encountered clinical and radiological entity found in this disease. Enteroliths are formed due to stasis caused by stricture formation in intestinal tuberculosis. We report a case of enterolithiasis secondary to intestinal tuberculosis.

Radiological analysis of interstitial lung diseases.

Aims and objectives: To diagnose interstitial lung diseases using HRCT and chest X-Ray and to study and compare the different radiography patterns evident in both conventional chest radiography and HRCT. Material and method: The present study was a prospective and observational (non interventional) type of study. This study aimed evaluating patients coming to the Radiology Department of Dhiraj General Hospital, by using X-RAY and CT scan so as to achieve aims and objectives outlined. Results: Of the 48 patients, 28 patients were males (58.33%) and 20 (41.67%) were females. The age of the patients ranged from 39 years to 80 years. The common diseases included in the study were idiopathic pulmonary fibrosis (25%), idiopathic NSIP (16.5%), rheumatoid arthritis (14.5%), lymphangitis carcinomatosis (8.33%). Conclusion: In our study, 48 patients were radiologically evaluated with X - ray and CT-Scan. Chest X is a primary modality used to screen patients with lung pathologies, being cheap, easy to perform and requires less radiation. HRCT is the modality of choice for diagnosis of interstital lung diseases.

Case series – Slipped capital femoral epiphysis in three members of same family as an unusual presentation.

Slipped capital femoral epiphysis is a disorder of the hip that affects children in late childhood and early adolescence, characterized by medial and posterior displacement of the proximal femoral epiphysis on the metaphysis. Although the diagnosis and treatment of slipped capital femoral epiphysis have been well described, the search for its cause and a method of early identification continues. We have reported here an interesting case of a bilateral slipped capital femoral epiphysis as an unusual presentation in one family -father and two siblings, had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis. epiphysis have been well described, the search for its cause and a method of early identification continues. We have reported here an interesting case of a bilateral slipped capital femoral epiphysis as an unusual presentation in one family-father and two siblings, had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis.

Satisfaction, self-use and perception of medical students in Majmaah University, Kingdom of Saudi Arabia, towards complementary and alternative medicine

Complementary and Alternative Medicine [CAM] is a growing industry in the health care system, and the use of CAM is rapidly evolving. In the Kingdom of Saudi Arabia [KSA], little research has addressed the satisfaction, use and perception of medical students towards CAM. The objectives of the current study were to assess the level of medical students' satisfaction and perception towards studying CAM and to determine their self-use of different modalities of CAM. This descriptive study was conducted by administering a questionnaire to the first and second batches of the medical students studying the CAM module at the College of Medicine, Majmaah University KSA. The instrument used in this study was a validated self-administered questionnaire, and the retrieved data were analysed using SPSS

A Study on Vasculature of The Suprarenal Glands.

Introduction: Suprarenal glands are among the most vascular organs in the body and they are richly supplied by the vasculature from the various sources. Suprarenal gland vasculature and its course characterized by the many unique features. Adrenal vascular studies are performed in order to identify benign or malignant, functioning or non-functioning lesions of the adrenal gland. However the vascular supply of adrenal gland is subject to a lot of variations and adequate knowledge of the arterial and venous vascularisation is of considerable importance in angiographic studies. Materials and Methods: Total number of specimens studied in the present work is 75. Number of foetal specimens studied in dissection is 50 and Numbers of adult specimens studied in dissection is 25. All specimens were preserved in 4% formaldehyde solution. Dissection method: The present study is done only by direct dissection method. All the specimens are cleaned with water to remove the clots. The aorta and inferior vena cava are injected with acetone and then cleaned with distilled water to remove the clots. Specimens kept in 5% formalin. Observations: Detailed study of vasculature of suprarenal glands along with the origin, course, branching pattern and point of entry into the gland were tabulated accordingly. Conclusion: The usual pattern of origin of superior, middle and inferior suprarenal arteries from inferior phrenic, aorta and renal arteries is found in the present study. A few variations in the origin of the superior suprarenal, middle and inferior suprarenal arteries are also found along with the few variations in the termination of the supra renal veins.

Isolation and partial characterization of human amniotic epithelial cells: the effect of trypsin

Despite the extensive information available in the literature, cell surface marker signature of human Amniotic Epithelial Cells [hAECs] remains controversial. The aim of the present study was to characterize immunophenotypic features, proliferative capacity and immunogenicity of hAECs. We also tested whether expression of some cell surface markers is influenced by the type of trypsin used for tissue digestion. Single cell suspensions of amniotic membranes from four human placentas were isolated by enzymatic digestion and expression of CD9, CD10, CD29, CD34, CD38, CD44, CD45, CD73, CD105, CD133, HLA-I, HLA-DR, HLA-G, SSEA-4, STRO-1 and OCT-4 was then evaluated by flow cytometry. The differential impact of four trypsin types on the yield and expression of CD105 and HLA-I was also determined. The proliferative capacity of cultured hAECs was assessed and compared in the presence and absence of Epidermal Growth Factor [EGF]. To test their immunogenicity, hAECs were injected into Balb/c mice and the reactivity of hyperimmunized sera was examined by immunofluorescence staining. Nearly all purified cells expressed mesenchymal markers, CD9, CD10, CD29, and CD73 and the embryonic marker, SSEA-4. A large proportion of the cells also expressed STRO-1 and OCT-4. The purified cells also expressed HLA-G and HLA-I. A very small proportion of hAECs expressed CD34, CD38, CD44, CD133 and HLA-DR. The type of trypsin used for enzymatic digestion affected both the percentage and expression of HLA-I and CD105. hAECs revealed substantial proliferative capacity only when cultured in the medium supplemented with EGF. These cells were shown to be capable of inducing high amounts of anti-donor antibodies. Here we provided evidence that hAECs are immunogenic cells with high level of HLA-I expression. Furthermore, this work highlighted the impact of isolation procedure on the immunophenotype of hAEC

Incidence of gestation diabetes and viral hepatitis in pregnant women

To study the incidence of gestational diabetes and viral hepatitis in pregnant womenpresnting in Islam Central Hospital Sialkot. Cross sectional study based on patients attending Islam Central Hospital, Sialkot. This study was carried out at Islam Central Hospital, Sialkot from 1[st] January 2012 to 30 November 2013. Two hundred pregnant women were selected randomly attending Islam Central Hospital, Sialkot. The data was collected on proforma. The written informed consent was obtained on the consent form and permission was taken from the hospital committees. Blood samples were taken for diagnoses of hepatitis and second sample was taken for fasting blood glucose and then 75gm glucose in one glass of water was given to the patients. After 2 hours, another plasma glucose test was taken. Gestational diabetes was diagnosed on the basis of fasting plasma glucose level > 126mg/dl, 2 hours post prandial plasma glucose level >199.8mg/dl and hepatitis was diagnosed by its kits. The age variation of pregnant women included in this study was as follows. 20 patients [10%] were of age 16-20 years, 102[51%] of age 21-30 years, 54[27%] of age 31-40 years and 24[12%] of age 41-50 years. 70 patients [35%] included in this study had undergone major surgery e.g., caesarean section while 130[65%] had not undergone any major surgery. 54[27%] pregnant women had history of blood transfusion and 146[73%] pregnant women had no history of blood transfusion. 158[79%] of the pregnant women had undergone minor procedure e.g., tooth extraction or ear piercing and 42[21%] had not undergone any minor procedure. 30[15%] of the pregnant women had history of miscarriage conducted by Dai and 170[85%] had no history of dai handling. The incidence of overweight/obesity was 138 [69%] in case of pregnant women and 62[31%] had no evidence of being overweight/obese. The incidence of gestational diabetes was 34[17%] in pregnant women and 166[83%] had no history of gestational diabetes. The incidence of viral hepatitis was 18 [9%] in pregnant women and 182 [91%] had no evidence of viral hepatitis. In this study, out of 9 cases, 3 cases [33.33%] were suffering from hepatitis A, 2 cases [22.22%] from hepatitis B and 4 cases [44.44%] were suffering from hepatitis C. As the hygienic conditions in our country are very poor and dietary habits include eating food containing high carbohydrates and fatty contents so the incidence of metabolic diseases is increasing. The sedentary life style is also becoming common in pregnant women in our country therefore the incidence of gestational diabetes and hepatitis is increasing day by day in pregnant women irrespective of age, occupation, socioeconomic status, residential area and gravidity status

Pattern of dermatoses of pregnancy in Bangladeshi women

To register the patterns of specific dermatoses of pregnancy in Bangladeshi pregnant women. A total of 327 pregnant women, aged 20-40 years, were selected by random sampling method. They were screened for specific dermatoses by detailed history and clinical examination. 43 pregnant females had specific dermatoses of pregnancy. Twenty one [48.8%] women had pruritic urticarial papules and plaques of pregnancy, followed by pruritic folliculitis of pregnancy in 11 [25.6%], pruritus gravidarum in 8 [18.6%], prurigo gestations of Besnier in 2 [4.7%] and papular dermatitis in 1 [2.3%] female. The majority of females with dermatoses were found in the 25-30 years age groups. The present study highlights the pattern of specific dermatoses of pregnancy in Bangladeshi pregnant women. It was felt that the obstetricians ignore and do not give much attention to pregnancy associated dermatoses causing exhaustive irritation and ill effect of mental disturbance.

Threatened Miscarriage as a predictor of obstetric outcome

It was to study pregnancy outcome in patients with threatened miscarriage as compared to patients who had no bleeding in early pregnancy. It was a prospective case control/cohort study. This study was carried out in department of Obs. and Gyn. Islam teaching hospital, Sialkot from 1[st] January 2012 to 31[st] December 2012. 100 patients were enrolled randomly to group A, who had vaginal bleeding with closed cervix in first half of pregnancy. 100 asymptomatic age matched controls were enrolled randomly to group B. Data recorded included demographic features and detailed pregnancy outcome. Overall adverse pregnancy outcome was significantly higher in group A as compared to group B [p value <0.05]. 15% of patients had miscarriage in group A, while 2.1% miscarried in group B [p value <0.01]. Similarly 18% patients had preterm delivery in group A as compared to group B with 3.2% rate [p value 0.001]. Threatened miscarriage is associated with adverse pregnancy outcomes. Most significantly miscarriage, preterm delivery and low birth weight of neonates

Frequency of latent tuberculosis among diabetics and non-diabetics

To determine the frequency of latent tuberculosis among diabetics and non-diabetics. Adescriptive cross sectional study. At Unit II, Department of Medicine, Benazir Bhutto Hospital, Rawalpindi from October 1,2009 to March 30,2010. Across sectional study was carried out in MUM, BBH Rawalpindi. All patients, male and female, both diabetic and non diabetic, above the age of 18 years, presenting in Out-Patient department for regular check up or follow up were included in the study. Mantoux test was carried out in all patients to find out the frequency of latent tuberculosis in diabetics and non diabetics. A total of 286 patients were initially inducted in the study. However by the end of study, 20 patients dropped out as they lost follow up. So 256 patients were finally included in the study. Amongst them 131 were diabetics i.e., 51.2% and 125 were non diabetics i.e., 48.8%. One hundred and seventeen were male i.e., 45.7% and 139 were female i.e., 54.3%. Mantoux test was carried out in all patients both diabetic and non diabetic. Out of 256 patients Mantoux test was positive in 33 patients i.e., 14.8%. Among diabetics Mantoux test was positive in 27 patients i.e., 10.5%. While among non diabetics Mantoux test was positive in 11 patients i.e., 4.3%, with a p value of .008.This shows that latent tuberculosis is more common in diabetics than non diabetics. Latent tuberculosis is more common in diabetics than non diabetics. Treatment of latent TB in diabetics may have a beneficial impact on TB control

Headache: a useful clinical feature in detecting serious underlying cause

To examine the utility of clinical features in detecting serious underlying causes of headache in patients presenting to an emergency room. Descriptive Observational Study. Pakistan Railway Hospital spanning over a period of one year from July 2010 to June2011. Medical records of the patients attending the Emergency Room with headache as the major complaint were studied. 312 patients presented to ER with a complaint of headache. Of these 7.7% [n=24] had malignant headache and 92.3% [n=288] had benign headache. One hundred and ninety six patients [62.8%] were women and 116 [37.2%] were men. In males there were 86.2% patients with benign headache and 13.8% with malignant headache. While in females 94.9% had benign and 4.1% malignant headache. Ninety percent of patients had altered consciousness at presentation proved to have malignant cause for their headache. This figure was 91% for limb weakness, 100% for papillary and gaze abnormalities, 89% for extensor plantar response, and 85% each for papilledema and neck rigidity. Females present at younger age with headache and tend to have benign than malignant headache in majority of cases. Males present at relatively older age and tend to have malignant than benign headache in majority of cases. Younger patients presenting with headache usually have benign and elderly patients usually have malignant illness as the cause of their headache. With a good history and thorough physical examination Imaging like CT Scan and MRI can be avoided