A Case Series of Histoid Leprosy with a Brief Comparison of the Clinical Features with that of Lepromatous Leprosy

Histoid leprosy (HL) is a rare highly bacilliferous variant of lepromatous leprosy (LL). We are describing here a case series of HL in a tertiary care centre along with a comparison of the clinical features with cases of LL encountered in the same centre. There were 6 cases of HL in our centre for the past 10 years accounting for 1.86% of the total number of leprosy cases. HL constituted 11.54% of the total LL cases. 4 cases were de novo HL and 2 cases due to relapse. Papules, plaques and nodules were the commonest primary skin lesions. The distribution was localised in HL, mainly confined to the upper and lower limbs, while in LL it was symmetrical and generalised and mainly localised to the trunk. Superciliary madarosis, ear lobe infiltration, glove and stocking type of anaesthesia were found in the majority of LL, while lacking in HL patients. Type 2 lepra reaction and Grade 2 disability was much more common in LL, than HL. A very important finding in this case series is that the mean BI and MI of HL was more than in LL. All the patients were given of MB-MDT for 12 months and in patients who had initial BI of 4+ or more were given 24 months treatment and there were no cases of relapse after release from treatment

Risk of future diabetes is as high with abnormal intermediate post-glucose response as with impaired glucose tolerance.

AIMS: This analysis was done to compare the risk of development of diabetes among subjects with impaired glucose tolerance (IGT) and early glucose intolerance (EGI; intermediary post glucose level > or = 160 mg/dl) when compared with normal (NGT). Profile of insulin secretion and insulin resistance was compared in a subgroup of subjects with EGI, IGT and diabetes. PATIENTS AND METHODS: A program on 'primary prevention of diabetes' was initiated and high risk subjects were encouraged to join the program and were followed up. Out of 4084 (M:F 2344:1740) subjects enrolled in the program, a total of 1659 (M:F 1044:615) subjects with mean age 41.3 +/- 10.2 years who had at least two follow up visits were selected for this analysis. OGTTs were performed once in every 6 months. The median follow up duration was 5 years. The conversion rate to diabetes in subjects with persistent IGT or EGI was determined. In a subgroup of subjects, NGT (n = 118), IGT (n = 68), EGI (n = 106) and new DM (n = 126), plasma insulin at fasting, 30 min and 2 hr were measured and insulin resistance (HOMA-IR) was calculated by HOMA method. Insulinogenic index (DeltaI/G) was also calculated. RESULTS: The rate of conversion of IGT 251 (40.5%) and EGI 210 (36.5%) subjects to diabetes was similar and significantly higher when compared with the NGT subjects 99 (21.3%). Similar results were noted both in men and women. By using ROC procedure, a cut - off value of one hour post glucose of > or = 160 mg/dl gave a sensitivity of 80% and specificity of 70% to detect abnormal glucose tolerance. In a subset of subjects studied, it was noted that subjects with EGI had significantly higher fasting insulin values than NGT. Insulin resistance (IR) was the highest in DM [Geometric mean (SD)] 6.6 (1.9)), followed by EGI (4.5 (2.3)) (p < 0.0001 vs NGT, 2.9 (2.4)) and IGT (3.9 (2.2)). Insulinogenic index was normal in EGI, NGT and IGT, and it was lower in DM in comparison with other groups. The multiple logistic regression analysis showed that EGI (odds ratio (OR) 2.11) and development of diabetes was strongly associated. The survival curve (time free from diabetes) showed that the median survival time for NGT, EGI and IGT were 18.7, 11.6 and 9.6 yrs respectively. CONCLUSION: EGI which is a distinct entity with abnormal intermediate glucose response in glucose tolerance test (GTT) appears to be a risk factor similar to IGT in the development of diabetes. They had higher insulin resistance with normal insulin secretion. Therefore, it is important to determine the intermediate value also during the GTT in addition to fasting and 2 hr post glucose values.

The hyponatremic hypertensive syndrome in renal artery stenosis: an infrequent cause of hyponatremia.

The hyponatremic hypertensive syndrome is a rare but serious complication of reno-vascular disease. The syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Hypertension is typically refractory to treatment. We report an 82-year-old patient with this syndrome and describe the results of an audit of the clinical records of patients admitted to a teaching hospital over a two-year period with confirmed renal artery stenosis and hyponatremia. The syndrome should be suspected in patients in whom severe hypertension is associated with hyponatremia without other apparent cause, especially in the presence of reno-vascular disease.

Impact of Joint National Committee VII recommendations on diabetic microvascular complications.

AIMS AND OBJECTIVE: To determine the impact of the Seventh Report of the Joint National Committee recommendations on microvascular complications in South Indian type 2 diabetic patients. MATERIAL AND METHODS: In this study, 457 type 2 diabetic patients and 500 age-matched healthy control subjects, with no history of hypertension were enrolled. Based on blood pressure measurements, they were assigned as Group I: Normal (SBP < 120 and DBP < 80 mmHg); Group II: Prehypertension (SBP 120-139 or DBP 80-89 mmHg); Group III: Stage I hypertension (SBP 140-159 or DBP 90-99 mmHg) and Group IV: Stage II hypertension (SBP > or = 160 or DBP > or = 100). RESULTS: Blood pressure readings in controls and diabetics were: normal in 46.8% and 16.2% (chi2 = 101.1, p < 0.0001), prehypertension in 33.2% and 52.5% (chi2 = 35.7, p < 0.0001), stage I hypertension in 15.2% and 26.3% (chi2 = 17.3, p < 0.0001), stage II hypertension in 4.8% and 5% respectively. Prevalence of retinopathy increased with increasing incidence of hypertension (trend chi2 = 10.7, p < 0.01). In the multivariate analysis, cholesterol was associated with prehypertension, and cholesterol and family history of hypertension were associated with stage I hypertension. Albuminuria, family history of hypertension and serum triglycerides were associated with stage II hypertension. CONCLUSION: More than half of the diabetic subjects were prehypertensives. As expected prevalence of other complications increased with increasing levels of blood pressure. This emphasizes the need to have regular check up for hypertension to reduce the morbidity from other complications.

An expert system for the diagnosis of epilepsy: results of a clinical trial.

BACKGROUND: Artificial intelligence is an area where computer systems are used to solve real-life problems that require expert human intelligence. Expert systems serve as an effective alternative to supplement the dearth of human experts in a narrow domain of applications. We developed an expert system named SEIZ using DIAGNOS (an expert system shell for diagnostic applications) for the diagnosis and management of epilepsy. METHODS: A clinical trial was done to test the reliability of SEIZ. The clinical and demographic data from the medical records of 50 patients with epilepsy who attended an epilepsy clinic were provided to the expert system. The system-generated diagnosis was compared with the clinical diagnosis. RESULTS: The seizure types and epileptic syndromes for the 50 patients included generalized -tonic-clonic seizure (14), absence (4), complex partial seizure (18), simple partial seizure (4), juvenile myoclonic epilepsy (5) and other epileptic syndromes (3). There were two cases of hysterical conversion reaction. There was concordance in the diagnosis between the expert system and clinician in 47 cases (94%). The overall sensitivity was 94% and the specificity was 100% for absence, generalized tonic-clonic seizures, simple partial seizures and juvenile myoclonic epilepsy; 94% for complex partial seizures and 98% for hysterical conversion reaction. CONCLUSION: This expert system could generate reliable diagnoses for patients with epilepsy. Such a system may be useful for a doctor in a remote or peripheral area where an expert on epilepsy is not available.

Survival in multiple myeloma in Kerala.

BACKGROUND. The reported incidence of multiple myeloma in India ranges from 0.5 to 1.2 per 100,000 but there have been few studies on the effect of treatment of this condition. We, therefore, analysed the clinical profile of patients in Kerala with myeloma, the treatment given and the factors affecting survival. METHODS. Case records of 142 patients with multiple myeloma treated at the Regional Cancer Centre, Trivandrum, between 1984 and 1989 were reviewed and abstracted. Chemotherapy (using melphalan and prednisolone) and radiotherapy were the treatment modalities. Survival analysis was done using the Kaplan-Meier estimates and multivariate analysis of factors affecting survival was performed using Cox's proportional hazards regression model. RESULTS. The mean age of the patients was 61 years and 90 were males. Bone pain and pallor were the most common presenting symptoms and the median survival was 30 months. A combination of melphalan and prednisolone was found to be well tolerated and achieved a survival rate of 62% at 5 years. Hemibody irradiation was beneficial in a small group of patients. On a multivariate analysis, Bence-Jones proteinuria, melphalan and prednisolone combination chemotherapy and response to treatment at 6 months were the most significant factors affecting survival. Socioeconomic status did not seem to influence survival. CONCLUSIONS. Melphalan and prednisolone chemotherapy achieves prolonged survival in myeloma. Radiotherapy can relieve symptoms and in a small group of patients hemibody irradiation can achieve prolonged remission. Further studies are required to identify the subgroups in which certain treatments are most effective in improving survival.

Epidemiological significance of indeterminate leprosy--a hospital based study.

An epidemiological analysis of 100 cases of indeterminate leprosy attending the Department of Dermatology and Venereology of Medical College Hospital, Trivandrum, is presented. It was found that indeterminate leprosy formed 13.23% of all cases of leprosy and 1.3% of all out-patients attending this department. Only 27% of patients with indeterminate leprosy were below 15 years of age. There was a predominance of males especially over 20 years of age. There was no history of contact with leprosy in any of the patients with indeterminate leprosy. All patients with indeterminate leprosy came for hypopigmented patches, suspecting leprosy. Majority had the disease for more than 6 months. Single lesion on the outer aspect of extremity was the most common presentation. The lepromin test was positive in only 2% of patients with indeterminate leprosy, while it was positive in 80% of control subjects. Three cases of dapsone resistance were suspected in this series. The epidemiological significance of the findings is discussed.

Carbon starvation mediated changes in carbohydrate metabolism in Neurospora crassa.

Carbon starvation conditions were found to increase the activities of gluconeogenic enzymes such as malic enzyme, cytosolic malate dehydrogenase and isocitrate lyase along with proteases and inhibition in glucose catabolic enzymes such as G6P dehydrogenase and FDP aldolase in Neurospora crassa.