Fatal invasive gastrointestinal fungal infection in three non-immunocompromised patients

The importance and frequency of invasive fungal infections in different organs, including the gastrointestinal tract, has increased due to excessive use of aggressive immunosuppressive and immunomodulatory drugs in malignant diseases and organ transplantations as well as increased infections with the human immunodeficiency virus [HIV]. Fungal infections in the small intestine or colon are usually part of a disseminated disease process and reach these organs through the bloodstream. Two of the patients were infants 10 and 15 days of age, while one was 23 years old. Patients presented with abdominal pain, intestinal obstruction, and rectal bleeding. Hirchsprung disease was suspected in the two infants. In the adult patient, the diagnosis was unclear. Mucormycosis was diagnosed in two out of three cases. It is imperative for clinicians to consider invasive mycosis in the differential diagnosis in patients of all ages with treatment-resistant severe abdominal pain, diarrhea and fever

Post-chemotherapy neuroblastoma-like differentiation in ewing sarcoma of humerus: report of a rare case with review of literature

A 21-year patient initially presented with a fracture of the humerus following minor trauma. A bone scan and biopsy were done due to the suspicion of pathological fracture and the biopsy confirmed the diagnosis of Ewing Sarcoma [EWS]. Two months after initial presentation, chemotherapy was started and 5 cycles were given over a span of 6 months. Surgical resection of the tumor was then performed. The post-chemotherapy resection specimen, on histological examination, showed the presence of areas of neuroblastoma-like differentiation in otherwise morphologically classic EWS. Cytogenetic analysis by FISH revealed EWSR1 gene rearrangement. Four similar cases have been reported earlier in literature, all in females below 20 years of age. Our case is unique as it is the first case of post-chemotherapy neuroblastoma-like differentiation of EWS in a 21-year male

Astroblastoma in a Young Female Patient: A Case Report and Literature Review of Clinicopathological, Radiological and Prognostic Characteristics and Current Treatment Strategies

Astroblastoma is an uncommon glial tumor with predominant manifestation in the young age. Herein, we report a case of 18-year-old astroblastoma female patient who presented with history of two months headache. Magnetic resonance imaging (MRI) of the brain demonstrated well circumscribed, intra-axial abnormal signal intensity lesion (size=5×4 cm²) in the right parieto-occipital region of the brain. The patient underwent complete surgical resection of the gross tumor, as confirmed by an early post-surgical MRI (i.e., within 24 hours of surgery). Histopathological examination revealed neoplastic lesion exhibiting perivascular pseudo-rosettes with centrally hyalinized blood vessel and focal nuclear pleomorphism. Immunohistochemistry staining illustrated reactivity for glial fibrillary acidic protein and integrase interactor 1 (INI-1). These features rendered the diagnosis of astroblastoma. A comprehensive review of the current literature to summarize the clinicopathological and radiological characteristics, prognostic factors and current treatment strategies of astroblastomas is also presented. Our study would expand the pool of this uncommon tumor towards its better understanding and optimal treatment.

Outcome after surgical repair of partial anomalous pulmonary venous connection

Objective: To review the operative results of 55 cases of partial anomalous pulmonary venous connection [PAPVC]

Methods: This retrospective case series of 55 cases of PAPVC operated from January 2011 to June 2016 at CPE Institute of cardiology, Multan. Baseline characteristics of patients, their operative findings and results were retrieved from the hospital record

Results: Operation for PAPVC was performed in 55 patients. Patient's age varied from 3-28 years [mean 12.56 +/- 7.49], their weight was 9-62 kg mean [25.61 +/- 16.28]. There were 41[74.5%] males and 14[25.5%] females. 49[89.0%] patients had right sided PAPVC associated with ASD moreover 3[5.4%] cases had right pulmonary vein draining into right atrium. While there was only one case having left sided PAPVC [1.8%] and two cases [3.6%] of bilateral PAPVC [4%]. Reassuringly, there was not a single mortality. However, one patient developed junctional rhythum, which was successfully controlled on amiodarone. SVC obstruction having 6mmHg gradient was observed in one case however patient is doing well and is on follow up since 9 months

Conclusion: Surgical correction of PAPVC generally carries highly reproducible results with low morbidity

Lymphangioma circumscriptum: clinicopathological spectrum of 29 cases

To describe the clinicopathological spectrum of Lymphangioma Circumscriptum [LC]. Observational case series. Department of Pathology and Microbiology, AKUH, Karachi, from 2002 to 2012. All reported cases of LC were retrieved from medical record. Clinical and pathological features were noted. Frequency percentages were determined. There were 29 cases of LC predominantly males [62%]. The mean age was 27.17 +/- 15.5 years. The commonest sites was anal/perianal region [24%] followed by extremities [17%] and tongue, [14%]. Vulval LC was seen in 3 patients. Two cases were described on scrotum. The lesions were most commonly suspected as viral warts, mole or polyp [in anal Region]. Vesicles with erosions and bleeding and localized growth were the usual clinical presentations. Four of the patients presented with swelling since birth. All were treated with surgical excision. Microscopic examination revealed acanthotic squamous epithelium with papillomatosis. The subepithelial region had collections of lymphatic channels composed of ectatic dilated vessels with serum and inflammatory cells in their lumina. The lymphatic channels were seen in deeper layers along with lymphocytic aggregates. Lymphangioma circumscriptum is a malformation of abnormal lymphatic channels with feeding cisterns in subcutaneous tissue. It is a benign lesion usually occurring in anal/perianal region and confused with warts. Surgical excision is preferred mode of treatment

Symptomatic surgically treated non-neoplastic cysts of the central nervous system: a clinicopathological study from Pakistan

To report clinicopathologic features of symptomatic surgically removed non-neoplastic cysts of the central nervous system [CNS]. Case series. The Aga Khan University Hospital, Karachi, from 2003 to 2012. All non-neoplastic CNS cysts reported during the study period were retrieved and reviewed. Age, gender, location, histologic type and clinical features were noted. A total of 124 cysts were diagnosed in the study period. These included 44 epidermoid cysts [mean age 30.5 +/- 13.8 years], 35 colloid cysts [mean age 31 +/- 13.2 years], 32 arachnoid cysts [mean age 24.8 +/- 20.2 years], 6 dermoid cysts, 3 enterogenous cysts and Rathke's cleft cysts each and 1 ependymal cyst. All cyst types mainly presented in young adults in both genders with signs and symptoms of a mass lesion. Non-neoplastic cyst mainly presented like a CNS mass lesion in young adults. Epidermoids were the most common type of these cysts in the present series followed by the colloid and the arachnoid cysts

Frequency and risk factors of hepatitis B and C in Afghan patients presenting to tertiary care hospital in Peshawar

To document the frequency and risk factors of Hepatits B and C in Afghan patients presenting to a tertiary care hospital in Peshawar. Descriptive study. Rehman Medical Institute [RMI], Peshawar from 1st January, 2012 to 31st December, 2012. A total of 2166 Afghan national were included in the study who underwent surgery in RMI through consecutive, non-probability sampling. Hepatits B surface antigen [HBsAg] and anti-HCV antibody tests were performed by ELISA method. All patients who were positive for either of the two or both were investigated by a researcher-administered questionnaire to find the risk factors for seropositivity of hepatitis. Out of a total of 2166 patients, 104 patients [4.8%] were found to be positive. Seventy-eight patients [75%] were HepBsAg positive while 24 patients [23%] were anti-HCV antibodies positive while 2 patients were positive for both viruses. Re-use of unsterilized syringes [23%] and history of previous surgery [19.2%] were the most common risk factors whereas no risk factor could be identified in 15 patients [14%]. Seventynine patients [76%] were newly diagnosed at time of test while 25 patients [24%] were known cases of either HBV or HCV. Only one patient had clinical/laboratory features of chronic liver disease while no patient had underwent Hep B vaccination or had hepatocellular carcinoma. A high seroprevalance of HBV and HCV was found in this study. Reuse of unsterilized syringes, history of previous surgery and tattoos piercing were found to be the most common risk factors

Efficacy of port-site and intraperitoneal application of bupivacaine in reducing early post-laparoscopic cholecystectomy pain

The aim of this study was to assess the analgesic efficacy of Bupivacaine application at port-site and intraperitoneal infiltration in patients with laparoscopic cholecystectomy. Randomized Controlled Clinical Trial. The study was conducted at Rehman Medical Institute [RMI] Peshawar, Pakistan from June 2009 to June 2012. Patients who underwent elective laparoscopic cholecystectomy during the study period were included in the study. Eighty patients were randomized into two groups, study group and control group. The study group received 40 ml of 0.25% bupivacaine intraoperatively as intraperitoneal infiltration and local infiltration at the port sites. Pain assessment was done using visual analogue pain score [VAS] of 0-10 at fixed intervals during .the first 24 hours post surgery. The mean VAS score in the study group was less as compared to the control group throughout the 24 hours assessment period, however this difference was statistically significant [p<0.001] only during the first three assessments at 1 hour, 4 hours and 8 hours post surgery. The analgesia requirement was also significantly [p<0.001] decreased in the study group. Port site and intraperitoneal application of local anesthetic bupivacaine significantly reduced pain during the first 8 hours post surgery and total analgesia requirement was also significantly reduced. It is a simple and easily applicable technique which increases patient comfort and can be safely used to decrease post operative pain in patients undergoing laparoscopic cholecystectomy

Management of acute pancreatitis: experience of a tertiary care hospital in Peshawar

To document the frequency, age, gender, etiology, mortality and morbidity of patients suffering from acute pancreatitis [AP] and managed at a tertiary care hospital. This prospective, descriptive, institution-based study was conducted in Department of Surgery, Rehman Medical Institute [RMI], Peshawar [Pakistan], from June 2010 to June 2013. All patients with acute pancreatitis admitted to our institute were managed with a set protocol. Consecutive, non-probability sampling was done. Data were collected from all patients by a single investigator using a researcher-administered questionnaire, which included patient demographics, various risk factors, treatment options, complications and mortality. A total of 47 patients were included in the study; 28 female and 19 male patients. Out of 47 patients 35 [74%] were of Afghan origin, while 12 [26%] were Pakistani. Majority of patients [57%] were between 20-40 years of age. Gall stone pancreatitis [GSP] was the cause of AP in 13 [28%], dyslipidemia in 9 [19%], and traumatic AP in one patient, while in 24 patients [51%] it was idiopathic. Ten [21%] patients developed pseudocyst. Out of a total of 47 patients, 3 [6%] expired. Patients suffering from acute pancreatitis and presenting to our hospital had a predominance of females. Majority of patients were between ages of 20-40 years. Idiopathic pancreatitis was the most common type followed by GSP. Mortality and morbidity in this study was low in comparison to other local studies

Histopthological spectrum of renal biopsies in pediatric population: an update

To determine the histological spectrum and indications of renal biopsies in pediatric population from birth to 16 year of age and to delineate any change in histological pattern with time and age at tertiary care hospital in Karachi. Cross sectional study. This study was carried out at Aga khan University Hospital Karachi over a period of 7.5 years from January 2006 to July 2014. A retrospective review of the computerized database of the histopathology department of Aga khan University hospital [AKUH] was carried out on children from birth to 16 years of age who underwent renal biopsy. All renal biopsy specimens were processed, cut and stained and evaluated under light microscopy and immune fluorescence technique. The indication and findings of these biopsies and demographic data such as age and sex were identified. Frequencies and percentages were used for categorical variables and mean +/- standard deviation for quantitative variables. SPSS version 19.0 for statistical analysis. Mean age was 11.5 years +/- 3.5years with an age range from 3 months to 16 years with majority of the patients over 10 years of age. Out of 128 patients 79[61.7%] were male and 49[38.3%] were female with a ratio of 1.6: 1.The most common indication observed for renal biopsy was Nephrotic syndrome seen in 75[58.6%] cases with 36 [28.1%] being steroid resistant variety followed by steroid sensitive 25 [19.5%]. Other indications observed were Nephritic syndrome 16 [12.5%], renal failure 13[10.2%] and lupus nephritis for classification 11[8.6%]. The most frequent renal disease observed was focal segmental glomerulosclerosis [FSGS] 38[29.7%]. Others being minimal change disease 19[14.8%], membranous glomerulonephritis 12 [9.4%]. The most frequent biopsyfinding in all age group was FSGS. The distribution of renal diseases in pediatric age group described is similar to that described in national and international literature with some differencesobserved.This study provides updated epidemiological information on childhood renal diseases

Effectiveness of procedure for prolapse and hemorrhoids in immediate postoperative period

To document the early outcome of stapled hemorrhoidopexy, the procedure for prolapsed and hemorrhoids [PPH]. Descriptive case series. Rehman Medical Institute [RMI], Peshawar; from May 2012 to May 2013. A total of 24 patients requiring surgical treatment for prolapsing hemorrhoids of degree II and III were included in the study. Outcome measures were postoperative pain, bleeding, sepsis, urinary retention, relief of preoperative symptoms, operation time and length of hospital stay. Mean age of patients was 46.8 year. All surgeries were performed under spinal anesthesia. Mean surgical time was 22.5 minutes. The average distance between the stapling line and the dentate line was 2.6 cm. Postoperative pain at rest and during defecation was mild to moderate after PPH. Healing time was shorter after PPH and no patient had perioperative or postoperative bleeding. Postoperative pain was mild to moderate in majority of patients. There were no intraoperative or postoperative complications. PPH was a safe procedure and resulted in swift recovery and earlier return to work

Trigeminal neuralgia [TN]: a case report on short-term follow up

Trigeminal neuralgia [TN] is one of the most common neuropathic syndromes. It is more common in females than males. This condition is described as a sudden severe pain, can be unilateral or it can be in the form of episodes. Patient conceive it as very severe pain which affects thequality of life and health status of the individual. The pain can be described as a sudden severe pain which is normally triggered by a slight stimulus like touch, eating, drinking, washing, and shaving or by any thermal changes. We report a case of a sixty five years old female patient who presented with right sided pain in upper and lower quadrant of the jaw which was not relived by medication. Investigations and regular follow up has revealed classical trigeminal neuralgia pattern

Culture sensitivity pattern in patients of chronic suppurative ottitis media

To compare the nasal obstruction following submucosal resection of inferior turbinate versus total inferior turbinectomy in patients with enlarged inferior turbinate. Randomized control trial CMH Rawalpindi from June 2007 to November 2007. Sixty patients of both gender clinically diagnosed to have inferior turbinate hypertrophy with history of nasal obstruction, not responding to medical treatment, having age >12 years with no history of previous nasal surgery were selected by convenience sampling. Thirty patients were treated by total inferior turbinectomy and thirty cases were treated by submucosal resection of inferior turbinate and results in terms of relief of nasal obstruction based on VAS [Visual Analogue Score] were observed with follow-up carried out at three weeks. Out of 30 cases managed by total inferior turbinectomy 83% cases showed marked improvement, and 17% had mild improvement in nasal obstruction 3 weeks after surgery. Among patients managed by submucosal resection 80% had marked, 17% had mild and 3% had no improvement of nasal obstruction. Submucosal resection of inferior turbinates and total inferior turbinectomy are almost equally effective for relief of nasal obstruction in patients with hypertrophic turbinate

Porcelain fused to metal [PFM] crowns and caries in adjacent teeth

To assess the discrepancies in marginal integrity and contact points of Porcelain Fused to Metal [PFM] crowns and its association with caries in adjacent teeth. Cross-sectional study. Dental section of the Aga Khan University Hospital, Karachi, from January to August 2009. Ninety six [96] patients with PFM crowns on maxillary and mandibular premolars and molars were included in this study. Single unit PFM crowns that were part of fixed bridge with at least one natural adjacent tooth were studied. PFM crown with no adjacent tooth or badly broken down teeth were excluded. Marginal integrity, contact points of PFM crowns and caries in adjacent teeth were assessed clinically and radiographically. The data was collected on a structured Proforma. Fisher's exact test was used for statistical analysis. Marginal overhang and marginal gaps on the mesial surfaces of PFM crowns were observed in 17.7% and 13.5% respectively. Tight contact points and open contacts of PFM crowns with adjacent teeth were 15.6% and 17.8% respectively on mesial surfaces. Caries were present in 33.3% and 20% of teeth present mesial and distal to PFM crowns respectively. The association of marginal discrepancy with caries in adjacent teeth was found significant [p= 0.002]. A significant association of faulty contact points and margins of PFM crowns with caries in adjacent teeth was found

Analysis of Efficacy & Safety of Inhaled Tiotropium and Tiotropium Plus Formoterol in COPD.

A randomized, open labeled comparative analysis for 2-week therapy of inhaled Tiotropium (T) (n=30) and Tiotropium plus Formoterol (TF) (n=30) once daily was carried in stable COPD patients. Objective parameters like lung functions (FEV1 and FVC), SBP, DBP, pulse and subjective parameters like improvement in respiratory symptoms & safety were assessed at baseline and after 2 weeks of treatment. Mean FEV1 was 1.0963±0.3826 & 1.1657±0.3701 as well as 1.1227±0.4129 & 1.2260±0.3830 before & after treatment with inhaled T & TF respectively. A statistically significant p<0.05 and p<0.001 improvement was only observed for FEV1 without significantly affecting other study parameters with two treatment modalities respectively when analyzed from respective base lines. However, on comparing the post drug improvement in objective & subjective parameters among T & TF treatment arms showed statistically insignificant p>0.05 variation. Both the regimens were well tolerated and no case warranted withdrawal of treatment. The present study suggests that in the treatment of COPD, inhaled long acting bronchodilators (T & TF) on comparison appear equally effective & safe.

Association of total leukocytic count and differential leukocytic count as bioinflammatory markers with the glycemia of animal model of diabetes

To measure the White blood counts [TLC and DLC] and see their association with the glycaemic status [fasting blood glucose, glycosylated Hb] of normal and diabetic rats. This experimental study was carried out at Animal house / National Reference Laboratory for Poultry Diseases [NRLPD], Animal Division of National Agriculture Research Centre [NARC] Islamabad, Department of Biochemistry and Molecular Biology Army Medical College Rawalpindi from December 2006 to January 2007. A total of 60 albino rats [30 normal and 30 diabetic] were included in the study. Leucocytic counts were done by the visual method. Care was observed not to count clumped red cell debris. Blood glucose levels were determined by applying glucose oxidase method and the determination of total HbAlc was done using its Diagnostic kit. Significant difference was observed in the values of fasting glucose [p<0.05] but no significant difference was present in the values of Glycosylated Hb [HbAlc] [p>0.05] after experimentation. Comparison of total leukocytic count in normal and diabetic groups [p>0.05] revealed no significant difference. There was also no significant difference found in the values of Neutrophils and Lymphocytes counts [p>0.05]. Because of inadequate values of monocytes, Eosinophils and Basophils in both groups; the statistical analysis revealed no significant results. In a rat model of diabetes mellitus, hyperglycaemia of short duration has no role in producing inflammation as is indicated by no rise in the levels of otal leukocytic counts [TLC and DLC]

Association of c-reactive protein as an inflammatory marker with the glycaemic status of the alloxan treated diabetic rats

To measure the level of C-reactive protein and find its association with the glycaemic status [fasting plasma glucose, glycosylated haemoglobin] of metabolically normal and diabetic albino rats. Total 60 Albino rats were included into [metabolically normal rats n=30; diabetic rats n =30]. Plasma glucose levels were determined by using glucose oxidase method while determination of total Hb and glycosylated hemoglobin [HbA[1]c] was done by diagnostic kit that uses weak cation-exchange resin to bind Hb. The% HbA[1]c was determined by measuring the absorbance at 415 nm of the glycosylated hemoglobin fraction and the total hemoglobin fraction. The ratio of the two absorbances gave the% of HbA[1]c. C-reactive protein was measured by the ELISA kit. Significant difference was found in the values of fasting glucose, of the normal and diabetic groups [p<0.05] but no significant difference was present in the values of HbA[1]c of both groups. There was no significant difference in the values of C-reactive protein of the normal and diabetic groups. Short duration hyperglycemia has no role in producing inflammation and raising the levels of bioinflammatory marker C-reactive protein

Van Der Woude syndrome: a rare case in Pakistan

Congenital epithelial anomalies of the face [sinus of fistula or pits] are uncommon. Most of them involve the lower lip as a part of Van der Woude syndrome. This syndrome presents as a pair of pits in the lower lip vermilion in association with left lip and palate. The incidence is 0.001% of the general population. Additional clinical features include enamel hypoplasia, multiple congenitally missing teeth and abnormality of right limb as a birth defect. Management of the patients involves the collaboration of different specialists. An earlier management of these cases could improve self-esteem and quality of life of the patient. Very few cases of this condition have been reported worldwide. By reporting such new cases we wish to contribute to the understanding of the etiology and to the better knowledge of the details of this very rare condition

Comparison of complications of septal surgery with and without use of intra-nasal splints

To compare the adhesion formation and post-operative pain with and without intranasal splints in patients undergoing septal surgery with inferior turbinectomy. Comparative study. The study was carried out in CMH Rawalpindi from April2005 to Oct 2005. Total 60 patients undergoing septal surgery were randomly divided into two groups. In Group A intranasal splints [made from plastic infusion bottles] were placed with paraffin gauze packing and in Group B, paraffin gauze packing was done without intranasal splints. Follow-up was carried out at 48 hours and 01 week after surgery for assessment of pain scores, while adhesion formation was monitored for two months after surgery. Mean age of patients in Group A [with splints] was 26.43 years and of Group B [without splints] was 25.77 years. There was marked difference of pain scores at 48 hrs after surgery between two groups and difference was found highly significant [p value 0.001]. The p-value of pain score for data at one week was 0.022, still significantly different but lesser than the one at 48 hrs. Only two patients both without splints were found to have adhesions [p value 0.150]. It is concluded that intranasal splints increased post-operative pain significantly and there was no significant benefit in reducing the post-operative adhesion formation with splints

Minimally invasive papillary carcinoma of the extrahepatic bile ducts

Invasive papillary carcinomas of the Extrahepatic Bile Ducts [EBD] are uncommon [4-5%]. The course is less aggressive than conventional adenocarcinomas of the extrahepatic bile ducts. Non-invasive and minimally invasive papillary carcinomas are even rarer, behave as in-situ carcinomas and are associated with excellent long-term prognosis. A variety of lesions of the EBD that show papillary architecture should be distinguished from papillary carcinoma. Here, we report a case of papillary carcinoma of the common bile duct showing minimal invasion. Separation of invasive from non-invasive or minimally invasive papillary carcinoma is critical in estimating the patient outcome