A rare scenario of perforated gastrointestinal stromal tumours of ileum

Gastro-intestinal stromal tumours (GIST) are among the common mesenchymal tumours of the gastro-intestinal (GI) tract. It varies in location and presentation. GIST are reported in the stomach frequently (60-70%), followed by small intestine (20-25%). Mainly GIST manifest typically with bleeding or vague abdominal pain and discomfort. The spontaneous perforation of GIST is very rare. We report case of a middle-age male patient who presented in emergency with pain in right lower abdomen associated with features of peritonism. After clinical evaluation and preliminary radiological investigations, a working diagnosis of perforated appendix was made. Patient was undertaken for emergency surgery. A diagnostic laparoscopy followed by midline laparotomy was done. Intra-operatively, a perforated and necrotic outpouching at antimesenteric border of terminal ileum was found. Histopathological examination of the resected part of ileum revealed compatibility with GIST. It was strongly positive for cluster of differentiation 117 (CD117) and smooth muscle actin. Patient received adjuvant therapy with Imatinib. A complete surgical resection without extensive lymph node sampling is the primary treatment option. As GIST are rare, a high index of suspicion is warranted for diagnosis and appropriate treatment.

Hydro-chemistry of groundwater in a North Indian city and its suitability assessment for drinking and irrigation purposes

Aim: The current study aimed to identify the hydro-geological processes that control the groundwater chemistry. Further, groundwater quality was also evaluated for drinking and irrigation purposes. Methodology: Groundwater samples were collected from a semi-arid region of North India i.e., Ellenabad, Sirsa, Haryana. The samples were analyzed following the American Public Health Association standard methods for the examination of water and wastewater. Results: Most of the groundwater samples of study area fall under hard category. The saline nature of groundwater can be attributed to high concentration of total dissolved salts (340±104 mg l-1). Majority of the groundwater samples showed fluoride concentration below the permissible limit of WHO and BIS (1.0 mg l-1). Multivariate analysis including sodium absorption ratio was calculated to assess the water quality for irrigation purpose and it was found appropriate for majority of crops, except for sensitive plant species. Interpretation: Potability assessment of groundwater showed that more than 40% samples were unacceptable for drinking purpose without any prior treatment, hence, it is essential to conduct a routine monitoring of groundwater to determine its aptness for drinking, domestic and agriculture purposes.

Ns1 Antigen Detection By Elisa In Early Laboratory Diagnosis Of Dengue Infection

Introduction: Dengue is a major public health problem in tropical and sub-tropical regions of the world and it is known for serious life threatening complications. Detection of IgM antibodies forms the mainstay for diagnosis of dengue infection. However, IgM antibodies develop after 4-5 days of infection and there is an urgent need for an alternative diagnostic tools that can detect dengue infection earlier. Aim and Objectives: To evaluate the efficacy of NS1 antigen ELISA for early diagnosis of dengue virus infection in a tertiary care hospital Methods-A total of 2106 serum samples from patients with suspected dengue infection were tested for dengue NS1 antigen and IgM anti-body detection by ELISA. Results: 765 (36.32%) were positive for dengue NS1 antigen and 857 (40.69%) were positive for dengue IgM antibody. NS1 antigen was detectable in patient sera from day 1 onwards however; dengue IgM anti-body was detected from day 3 onwards. Out of 765 NS1 antigen positive samples, 562 (73.46%) were positive in acute phase of illness and 203 (26.54%) were positive in convalescent phase of illness. Out of 857 MAC ELISA positive samples, 312 (36.41%) were from acute phase of illness and 545 (63.59%) were from early convalescent phase of illness. Combination of two tests resulted in increase in the positivity rate to 52.66% as against to independent posi-tivity rate of 36.32% of NS1 ELISA and 40.69% of MAC ELISA. Conclusion: Combined use of NS1 antigen assay with MAC ELISA test could significantly improve diagnostic sensitivity of dengue infection

Study of Nocardia in HIV positive chest symptomatic individuals.

Introduction: Pulmonary nocardiosis is a well-described infection in patients with neoplastic disease, human immunodeficiency virus (HIV) infection. The radiographic appearance of pulmonary nocardiosis is varied and nonspecific. Since the clinical and radiologic manifestations are non-specific, and the microbiological diagnosis is often difficult. In some patients, pulmonary nocardiosis will be mistaken for other infections, such as tuberculosis or bacterial pneumonia. Hence this study was undertaken to detect the prevalence of nocardiasis in HIV infected patients. Material and Methods: One hundred chest symptomatic patients screened for HIV infection and the samples of HIV positive patient processed for Nocardia using kinyoun’s modification of zeihl Neelsen stain and culture. The CD4 count of HIV patients with Nocardial infection and co-infection by mycobacterium tuberculosis studied. Observations: Out of 100 patients with cough and fever more than 2 weeks, 58 turned out to be HIV positive. Most of the patients included in the study were in their 3rd and 4th decades of life. The male to female ratio was 1:0.38. The open tuberculosis cases were 43.45% and sputum positive for acid fast bacilli. The nocardiosis was observed in 3.45% cases by modified Kinyoun’s method of staining and culture. In 80.65% tuberculosis cases, CD4 count less than 200/μl, while 19.35% had CD4 count more than 200/μl. The cases with nocardiosis had CD4 count less than 200/μl. Co-infection with tuberculosis and nocardiosis is not observed. The history of family contact for tuberculosis was found in 9.68% cases. Conclusion: The prevalence of nocardia in HIV positive individuals for north Maharashtra region is observed. The nocardia are easy to treat if diagnosed correctly and this will help in preventing morbidity in chest symptomatic patients. Unnecessary treatment with higher antibiotics can be avoided and cost effective treatment will be possible. Patients with CD4+ count less than 200 cells/μl should be screened for Nocardia. [Ravindra K NJIRM 2016; 7(5):73-77]

Evident stabilization of the clinical profile in HIV/AIDS as evaluated in an open label clinical trial using a polyherbal formulation.

Background & objectives: The complementary and alternative medicines (CAM) have not been systematically evaluated for the management of HIV/AIDS patients. In a prospective, single-site, open-label, non-randomized, controlled, pilot trial, we evaluated a polyherbal formulation (PHF) for its safety and efficacy in treating subjects with HIV-AIDS. Methods: A total of 32 and 31 subjects were enrolled under the PHF and highly active antiretroviral treatment (HAART) arms, respectively, and followed up for a period of 24 months. Plasma viral RNA, CD4 cell count and blood chemistry were monitored at 3-month intervals. Following mid-term safety evaluation, 12 subjects from the PHF arm were shifted to HAART and were followed separately as PHF-to-HAART arm, for the rest of the period. Results: The HAART arm was characterized by significant improvements in CD4 cell count (154.4 cells/μl/year, P<0.001) and reduction in plasma viral load within 3 to 6 months (-0.431+ 0.004 log10 IU/month, P<0.001). In contrast, the PHF arm showed a profile of CD4 cell loss at remarkably slower kinetics (14.3 cells/μl/year, P=0.021) and insignificant reduction in the viral load. The PHF and HAART arms did not differ significantly in the occurrence of AIDS-related illnesses over the study period of 24 months. In the PHF-to-HAART arm, the rates of CD4 count and reduction in viral load were significant and comparable to that of the HAART group. In the PHF arm, at 1 month, a significant increase in CD4 cell count and a concomitant decrease in viral load were seen. Interpretation & conclusions: The PHF appears to have provided protection by delaying the kinetics of CD4 cell reduction. Given the several study limitations, drawing assertive inferences from the data is challenging. Future studies with a stringent study design are warranted to confirm these findings.

Chandipura virus encephalitis outbreak among children in Nagpur division, Maharashtra, 2007.

Background & objectives: An outbreak of acute encephalitis syndrome (AES) among children from Nagpur division, Maharashtra was investigated to confirm the aetiology and to describe clinico-epidemiological features. Methods: AES cases among children <15 yr, from Nagpur division, hospitalized between June-September 2007, were investigated. Serum and cerebrospinal fluid (CSF) were tested for IgM antibodies against Chandipura virus (CHPV) and Japanese encephalitis virus (JEV) and for CHPV RNA by RT-PCR. Partial N gene sequences were used for phylogenetic analysis. Virus isolations were attempted in rhabdomyosarcoma (RD) cell line. Sandflies were collected, pooled and tested for CHPV RNA by RT-PCR. Results: A total of 78 AES cases were recorded in children <15 yr of age. Case fatality ratio was 43.6 per cent. Male to female ratio was 1:1.2. Chandipura (CHP) was confirmed in 39 cases. CHPV RNA was detected in both CSF and serum specimens of 2 cases and in serum of 22 cases. Phylogenetic analysis showed 99.98 – 100 per cent nucleotide identity in the sequences studied. Anti-CHPV IgM antibodies were detected in CSF of 2 cases and in serum of 8 cases. Seroconversion to anti-CHPV IgM antibodies was observed in 5 cases. Clinical manifestations of CHP cases (n=38) were fever (100%), convulsion (76.3%), altered sensorium (34.2%), headache (23.7%), vomiting (44.7%) and diarrhoea (23.7%). CHPV RNA was detected in one of two pools of sandflies from affected locality. Interpretation & conclusions: Chandipura virus was confirmed as the aetiological agent of this acute encephalitis outbreak with high case-fatality among children.

A study of the levels of serum malondialdehyde, alpha tocopherol, beta carotene and vitamin c after micronutrient supplementation during alcohol rehabilitation.

This study was undertaken to test the effect of a 21-day supplementation of antioxidant nutrients on biochemical indicators of lipid peroxidation, and vitamin levels in alcohol-dependent patients during a program of alcohol rehabilitation. A randomized double-blind trial was performed comparing two groups receiving daily either a combination of micronutrients (vitamin A 5000 IU, vitamin D3 400 IU, vitamin E 15 mg, vitamin B1 IP 5mg, vitamin B2 IP 5mg, nicotinamide IP 45mg, D-panthenol IP 5mg, vitamin B6 IP 2mg, vitamin C IP 75 mg, folic acid 1000mcg, vitamin B12 IP 5mcg, dibasic calcium phosphate IP 70 mg, copper sulphate BP 0.1mg, zinc sulphate monohydrate USP 28.7, potassium iodide IP 0.025 mg, light magnesium oxide IP 0.15 mg) or a non-supplemented group. 160 male alcohol-dependent patients, 25–45 years of age without severe liver disease, hospitalized for a 21-day rehabilitation program were included. Serum malondialdehyde, α-tocopherol, β-carotene and vitamin C were measured in serum, initially and after supplementation. In the non-supplemented group, serum concentrations of malondialdehyde decreased significantly (p<0.05) and vitamin C significantly increased (p<0.001), whereas α-tocopherol and β-carotene concentrations were unaffected. At the end of the hospital stay, serum indicators were significantly improved in the supplemented group as compared to the non-supplemented group for α-tocopherol, β-carotene and serum malondialdehyde (p<0.001). The results indicate that a short-term supplementation with physiological doses of antioxidant vitamins during alcohol rehabilitation clearly improves micronutrient status indicators, and reduces oxidative stress.

Serum nitrate levels in alcoholic patients: a study in an urban government hospital and de-addiction centre.

This study was designed to determine the nitric oxide metabolism measured as circulating nitrate levels in the serum of alcoholic patients. Nitric oxide (NO) plays a significant role in the inflammatory process and has been implicated in several autoimmune disorders. This study was carried out prospectively to estimate the levels of nitrate in the serum, as a surrogate marker of NO production, among alcohol-dependent patients. Serum nitrate concentrations as an index of plasma NO levels were assessed in alcohol-dependent patients attending the deaddiction centre of a major hospital. Total sample size comprised 450 males. Age- and sex-matched non-alcoholic control population (n=90) was compared with alcoholics (n=360) of similar socioeconomic status. Serum nitrate concentration was assayed spectrophotometrically. Stable metabolites of nitrates were significantly higher in alcoholics compared with their nonalcoholic controls (p<0.05). The results may support the involvement of oxidative damage due to high NO concentration, and may be linked to its excitotoxicity and cytotoxicity in neurons, glia, and myelin. Generation of NO has been linked to an increased tendency towards tolerance to alcohol.

Pseudocyst of ectopic pancreas of the duodenal wall masquerading as malignant cystic tumor of Pancreas

We report a patient who underwent pancreaticoduodenectomy for a cystic lesion in the region of the pancreatic head and duodenum. Preoperatively, we had suspected a malignant lesion; however, it turned out to be ectopic pancreatic tissue in the duodenal wall, with the changes of chronic pancreatitis and pseudocyst formation. With this report we seek to highlight the rarity of this particular pathologic combination and the difficulties in its correct preoperative diagnosis and management

Oculosporidiosis in a tertiary care hospital of western Orissa, India: a case series.

The authors present a case series of 54 subjects of Rhinosporidium. They were reported in two years at a tertiary care hospital of Western Orissa. The clinically diagnosed cases by ophthalmologists were confirmed by histopathological samples following surgery. In our series, we noted Rhinosporidium seeberi organisms as the main causative agent. Males were affected three times more than females. Children less than 10 years of age comprised more than 50% of our series. In 91% of cases, the conjunctiva was the site of this infection. Total excision of fungal mass was carried out in all cases and two cases had recurrence between 9 and 12 months following intervention. Although this is an endemic area for such infestation, unilateral manifestation observed in all cases is interesting to note. Low recurrence rate in limited follow-up period could be due to early detection and standard management.

Asymptomatic T-tube remnant in common bile duct.

A 46-year-old lady presented with itching, five years after a primary common bile duct repair following cholecystectomy. Prior to this she underwent an interno-external biliary drainage. At laparotomy the horizontal limb of a T-tube was found in the common hepatic duct. Eleven months after a Roux loop hepatico-jejunostomy she is asymptomatic.

Superior mesenteric artery syndrome following ileo-anal pouch procedure.

A rare complication following ileo-anal pouch procedure is the occurrence of superior mesenteric artery syndrome. We report a patient with ulcerative colitis who developed vascular compression of the duodenum following J-pouch construction.

Segment IV liver cyst with biliary communication following laparoscopic deroofing.

Simple cysts of the liver rarely have a biliary communication. We record the development of a biliary communication following laparoscopic deroofing of a segment IV simple cyst of liver and document its successful sclerosis with tetracycline.

Choledochoduodenostomy: influence of risk factors in post-operative morbidity.

BACKGROUND: Choledochoduodenostomy is performed for a variety of lower common bile duct lesions. AIMS: To analyse the influence of risk factors on the post-operative morbidity following choledochoduodenostomy. METHODS: Relation of risk factors including age more than 60 years, medical Illness, hemoglobin less than 10 g/dL, albumin less than 3 g/dL, bilirubin more than 10m/dL, presence of cholangitis at admission (treated pre-operatively), use of pre-operative endoscopic sphincterotomy and common bile duct diameter at surgery were related to the occurrence of post-operative morbidity was studied using univariate analysis. RESULTS: Fifty patients underwent choledochoduodenostomy. One patient (2%) died; major post-operative morbidity occurred in 12 patients (24%). Presence of cholangitis at admission was the only factor related (p = 0.00012) to the occurrence of post-operative morbidity. No long-term complications were encountered in 35 patients (70%) mean with followup period of 28 (range 8-60) months. CONCLUSIONS: Choledochoduodenostomy is a safe permanent drainage procedure for benign lower biliary obstruction.

Transcholedochal cholecystolithotomy for a variant of Mirizzi's syndrome.

Obstruction of the common bile duct by impaction of a gallstone in the neck or the cystic duct of the gallbladder results into repeated attacks of cholangitis (Mirizzi's syndrome). In suspected cases preoperative diagnosis can be made by ultrasonography and cholangiography. We report two patients of a variant of Mirizzi's syndrome. The common bile duct was obstructed by a stone impacted in the neck and causing extrinsic compression from behind. Ultrasonography and endoscopic retrograde cholangiography diagnosed the condition as common bile duct stone in both the cases. The anomaly could be diagnosed only after choledochotomy. Stones were retrieved by transcholedochal cholecystolithotomy--an innovative surgical procedure for this variant of Mirizzi's syndrome.

Takayasu's disease in an Arab male: relationship with tuberculosis

A case widespread Takayaus's disease [type III] affecting an Arab male is reported. He presented with a radiological picture of 'reversed coarctation'. He had been treated for pulmonary tuberculosis in the past. The relationship between Takayasu's is disease and tuberculosis is discussed. To the best our knowledge, this is the first reported case from Saudi Arabia

Abnormal systolic time intervals in asymptomatic Saudi diabetics

Systolic time intervals were recorded in 21 asymptomatic Saudi male diabetics and 16 controls between the ages of 40 and 60 years, before and after maximal exercise. Diabetics had significantly prolonged PEP and PEP/LVET at rest which improved on exercise. This reflects preclinical involvement of the heart even though the diabetes is of short duration. Such simple non-invasive tests may be of value in selecting diabetics at high risk of cardiovascular complications