Acquired Toxoplasmosis Presenting with a Brainstem Granuloma in an Immunocompetent Adolescent.

Background: Toxoplasmosis is an uncommon disease in immunocompetent people. Case characteristics: We report an adolescent boy with central nervous system toxoplasmosis who presented with progressive lower cranial nerve palsies and a ring-enhancing lesion on neuroimaging. Intervention: Diagnosis of toxoplasmosis was confirmed on histopathology of the excised lesion. Message: Toxoplasmosis should be considered in the differential diagnosis of focal brain lesions irrespective of immune status.

Pediatric Vasculitides: A Generalists Approach.

Vasculitis is defined as the presence of inflammation in a blood vessel that may occur as a primary process or secondary to an underlying disease. Primary vasculitides are rare in children. These are defined by both the size of vessels involved and the type of inflammatory response. Clinical features consist of multi-organ involvement on a background of constitutional features reflecting the size and location of the blood vessels involved. Whilst some vasculitides are best diagnosed clinically, many forms require sophisticated imaging and other investigations (auto antibodies) to reveal the correct diagnosis. Prompt recognition and treatment is crucial as many of the vasculitides cause significant morbidity or mortality. Treatment options range from symptomatic therapy, immunosuppresive agents, intravenous immunoglobulin (IVIG) or biologic agents and are determined by the type of vasculitis, the severity of the inflammation, and the organ systems affected. Early detection and aggressive treatment is crucial for the best outcomes in the most severe forms of childhood vasculitis.

Duchenne and Becker muscular dystrophies: An Indian update on genetics and rehabilitation.

The application of molecular diagnostic techniques has greatly improved the diagnosis, carrier detection, prenatal testing and genetic counseling for families with Duchenne and Becker muscular dystrophy (D/BMD) in India. The prediction of Duchenne muscular dystrophy (DMD) patients to have out-framed deletions and Becker's muscular dystrophy (BMD) patients to have in-frame deletions of dystrophin gene holds well in the vast majority of cases. Mutation detection is obviously critical for diagnosis but it may also be important for future therapeutic purposes. These factors underscore the need for earlier referral, genetic counseling and provision of support and rehabilitation services which are the main priorities for psychosocial assessment and intervention at medical and social levels.

Limited joint mobility and plantar pressure in type 1 diabetic subjects in India.

AIM: Limited joint mobility and plantar pressure in the foot has not been assessed in type 1 diabetes. The aim of this study was to investigate the joint mobility and plantar foot pressure in Asian Indian type 1 diabetic subjects and to see its association with duration of diabetes. MATERIAL AND METHODS: The joint mobility and plantar pressure were measured in 115 consecutive subjects attending the foot clinic. The study groups were: Control- non diabetic controls (n=40) (M:F 19:21) and type 1 diabetic patients (n=75) (M:F 42:33). Joint mobility was assessed using a goniometer at two sites, in the subtalar joint and in the hallux. Plantar pressure was measured using the RS-Scan platform system. Data obtained on the metatarsal heads were used for analysis. RESULTS: Patients with type 1 diabetes had significantly lesser joint mobility (p < 0.0001) and higher plantar pressure (p < 0.0001) compared with the control group. Duration of diabetes had an inverse association with joint mobility (p < 0.0001). The degree of joint mobility was more restricted in patients with longer duration of diabetes. Plantar pressure increased with increasing duration of diabetes. CONCLUSION: In conclusion, type 1 diabetic patients in India had limited joint mobility which decreased further with longer duration of diabetes and they had high plantar pressure also.

Wolfram syndrome.

Wolfram syndrome is a rare neurodegenerative and genetic disorder, which should be suspected in patients with young onset non-immune insulin dependent diabetes mellitus and optic atrophy. Patients are most likely to develop diabetes insipidus, deafness, urinary tract, and neurological abnormalities. 60% of the people with Wolfram syndrome die at age 35, usually due to central respiratory center failure following brain stem atrophy. Though there is no treatment to reverse the underlying mechanism of neurodegeneration, early diagnosis and adequate hormonal replacement could improve quality of life and survival.

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.

Profile of diabetic foot complications and its associated complications--a multicentric study from India.

AIM: The aims of this study were to determine. The prevalence of foot complications such as neuropathy, peripheral vascular disease (PVD), amputations and infections and the associated diabetic complications and practice of foot care among these subjects. METHODS: A total of 1319 type 2 diabetic patients, were selected from four different centres across India. The centres were Diabetes Research Centre (DRC), Chennai, Government Rajaji Hospital (GRH), Madurai, Christian Medical College (CMC), Vellore and All India Institute of Medical Science (AIIMS), Delhi. Details were collected regarding foot problems and associated complications. RESULTS: The prevalence of neuropathy was 15% (n=193) and PVD was 5% (n=64). Infections were present in 7.6% (n=100) of patients. The infection rate varied from 6-11% in the different centres. Nearly 3% of subjects had undergone a minor or major amputation. DISCUSSION: This study found that the prevalence of infection was 6-11% and prevalence of amputation was 3% in type 2 diabetic patients. Neuropathy (15%) was found to be an important risk factor for diabetic foot infections. Effective foot care advice should be propagated to reduce the burden imposed by diabetic foot complication particularly in developing countries like India.

Percutaneous closure of iatrogenic femoral arteriovenous fistula using endovascular covered stent.

Local complications after femoral arterial catheterization, such as hematomas, pseudoaneurysms, arteriovenous fistulas (AV fistulas), and arterial occlusions, are becoming more common, with the growing number of complex invasive procedures being undertaken, especially in older and sicker patients. Newer percutaneous techniques are being developed to treat these. Covered stents are an effective, safe, and less invasive way to deal with pseudoaneurysms and AV fistulas. This case report highlights the application of this technique to treat an iatrogenic femoral AV fistula in a 69 years male.

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.

Persistent microalbuminuria in type 1 diabetic subjects in South India.

AIM: There are only a few reports on the prevalence of microalbuminuria (MAU) in type 1 diabetic subjects in India. This study was done to assess the prevalence of MAU in South Indian diabetic subjects. MATERIAL AND METHODS: MAU was estimated by measuring albumin/creatinine ratio in an early morning urine sample on three occasions using immunoturbidimetry (> 30 microg albumin/mg creatinine) in South Indian patients. Kidney function tests were done in 95 type 1 DM, (M:F, 56:39). Persistent proteinuria was detected in 17 (17.9%) and they were excluded from the study. Further details were taken only in the remaining 78 subjects. Persistent MAU was seen in 22 (28.2%) and other 56 subjects had normoalbuminuria (NAU) (71.8%). RESULTS: There was no significant difference in the age, duration of DM and the average HbAlc between MAU and NAU. MAU developed at the age of > or = 20 years, even in subjects with onset of diabetes at a younger age. Diabetic retinopathy was present in 3 (13.6%) and ECG abnormalities were seen in one patient with MAU. None of the subjects in NAU group had these abnormalities. Prevalence of MAU increased with increasing duration of diabetes, MAU was present in 3 patients (10.3%) with duration of diabetes < or = 5 years, in five patients (23.8%) with duration of diabetes> 5 to < or = 10 years and in 14 (50%) patients with duration of diabetes > 10 years. Hypertension was present in 5 (22.7%) of MAU and only in one subject with NAU. CONCLUSION: It is observed that MAU occurs in type 1 diabetes after the age of 20 years and it is present in a large proportion of the study subjects.

Plasma homocysteine concentration and coronary artery disease in Asian Indians.

OBJECTIVE: This study was done (a) to evaluate the relationship between the plasma total homocysteine (tHcy) levels and coronary artery disease (CAD) in Asian Indians and (b) to see the relationship between tHcy and glucose intolerance. METHODS: Fasting concentrations of plasma tHcy was measured in 137 men, aged > or = 25 years who underwent coronary angiography while investigating for chest pain. Among them 71 had no CAD and 66 had CAD. Fasting plasma glucose (FPG) and glycosylated haemoglobin (HbA1c) were estimated. Total Hcy was measured using the Elisa method (Axis Biochemicals ASA-Oslo, Norway) in fasting EDTA plasma. RESULTS: The subjects with CAD were significantly older but had similar body mass index (BMI), waist-hip ratio (WHR), FPG and HbA1c values compared with the non-CAD subjects (P < 0.001). The median tHcy and the percentages of abnormal values were similar in non-CAD and CAD groups. No significant differences were seen in the four subgroups with respect to the mean tHcy or the percentage of abnormal values. The highest tHcy values were seen in the non-diabetic, non-CAD group (group 1--control). CONCLUSION: This preliminary data indicates that tHcy concentrations are not elevated in subjects with CAD and probably there is no association between total homocysteine and CAD in Indians. Homocysteine values were not influenced by the glucose tolerance status. Measurement of homocysteine concentrations may be more appropriate when the blood levels of vitamin B12 and folate are also measured.

Prevalence of pathogens in diabetic foot infection in South Indian type 2 diabetic patients.

AIM: To determine the prevalence of pathogens in diabetic foot infections, in relation to parameters like Wagner's grading, duration of diabetes and healing time. MATERIAL AND METHODS: A group of 654 (M:F, 433:221) type 2 diabetic patients with foot ulcers were studied. Specimens like pus, wound exudate and tissue were processed for smear for Gram's staining, aerobic and anaerobic culture, and biochemical identifications. RESULTS: In 654 diabetic patients, 728 pathogens were isolated. Aerobic pathogens were isolated in 437 (66.8%) patients and anaerobic pathogens were isolated in 217 (33.2%). As Wagner's grading increased, the prevalence of anaerobic pathogens also increased. Neuropathy was common in diabetic patients infected with both aerobic and anaerobic pathogens. Ulcers infected with anaerobic pathogens showed a longer healing time than ulcers infected with aerobic pathogens. There was no significant difference in peripheral vascular disease (PVD) in patients selected for the study. Among aerobic pathogens, Enterobacteriaceae family (48%), Staphylococcus species (spp) (18.2%), Streptococcus spp (16.8%) and Pseudomonas spp (17%) were seen frequently. Among anaerobes Peptostreptococcus spp and Clostridium spp formed 69.4%. Gram-negative anaerobes like Bacteroides spp and Fusobacterium spp were present in 30.6%. Healing time was longer when strict aerobic pathogen Pseudomonas spp and strict anaerobic pathogens were present (136.1 +/- 28.6 and 136.4 +/- 34.7 days, respectively). CONCLUSIONS: Diabetic foot infection is polymicrobial in nature. The healing time of wound infected with anaerobic pathogens was higher than those infected with aerobic pathogens. Anaerobic pathogens increased with the Wagner's grading. Presence of neuropathy increased the risk of foot infection.

Is increased apolipoprotein B-A major factor enhancing the risk of coronary artery disease in type 2 diabetes?

OBJECTIVES: An association of Apolipoprotein B (Apo B) with coronary artery disease (CAD) independent of LDL cholesterol (LDLc) concentrations has been reported in white population. This analysis was taken up to study whether the higher CAD risk in Asian Indians with diabetes could be explained by possible alterations in Apo B and Apolipoprotein A1 (Apo A1) concentrations. METHODS: The study group consisted of four hundred and forty seven men aged > or = 25 years, 167 with CAD and 280 with no CAD, classified by coronary angiography. Plasma lipid profile including total cholesterol, LDLc, Apo A1 and Apo B were done. Glucose tolerance was evaluated in all. RESULTS: Age, BMI, Apo B, and Apo A1 were significantly associated with CAD in a multiple regression analysis. Hyper Apo B was more common than hyper LDLc in CAD (73.6% vs 20.4%, chi2 = 157, P < 0.001). Apo B concentrations were increased in diabetic subjects even in the presence of normal levels of LDLc and in the absence of CAD. CONCLUSIONS: The study has shown that the apolipoproteins B and A1 provide better information regarding the risk of CAD. Apo B abnormalities exist in large percentages of CAD subjects despite having normal levels of LDLc. Diabetes per se enhances the Apo B concentrations and this could probably be one of the mechanisms of accelerated CAD in diabetes. Hyper Apo B may be an index of CAD risk.

Need for education on footcare in diabetic patients in India.

OBJECTIVES: The patient himself plays the crucial role in the prevention of diabetic foot disease and therefore education on foot care is important. In this study, we have evaluated the knowledge of the diabetic subjects regarding the foot problems and the care of feet in order to identify areas that require stress in the education programme. PATIENTS AND METHODS: Two hundred and fifty, consecutive cases of Type 2 diabetes (M:F, 176:74, age 57.2 +/- 9.7 yrs, duration 12.9 +/- 7.9 yrs) were selected for this study from the out-patient department of our hospital. A questionnaire was filled up for each patient by personal interview. The total score was 100 and a score of < 50 was considered as a low score for foot care knowledge. RESULTS: A score of < 50 was obtained in 67.2%. Low score was more common in women (78.5%) than in men (62.5%) (chi 2 = 5.26, P = 0.022). Low scores (< 50) were more common among those with lower level of formal education (chi 2 = 70.0, P < 0.0001), there were more women with low educational status. Significant foot problems like gangrene, foot ulcers were present in 27.2% and low scores were more common among those with these complications (82% vs 62%) (chi 2 = 8.3, P = 0.004). In general the scores on awareness of general foot care principles and basic facts about the foot complications were poor. Most of them (72%) had good knowledge about the right usage of foot wear. There was a trend to have lower scores with poor formal education (chi 2 = 51.1, P < 0.0001) and also with increasing age. There was no correlation between the scores and the number of hospital visits. Multiple linear regression analyses showed that 31.2% of the variations in the scores were explained by the level of education. CONCLUSIONS: This study underscores the importance of patient education on foot care principles, especially so, considering the magnitude of the problem of diabetes and the lower levels of literacy and poor socio economic status of many patients in this country.