Rare case of hereditary spherocytosis with rheumatic mitral stenosis

A rare case of hereditary spherocytosis (HS) and rheumatic mitral stenosis coexisting in a patient having severe stenosis, atrial fibrillation, and symptoms of the left ventricular dysfunction, along with hemolytic anemia attributed to HS. We present the case of a 58-year-old lady who presented to the emergency department with complaints of increasing shortness of breath for the past week. She was examined to have atrial fibrillation with a fast ventricular rate. On investigations, she was found to have severe rheumatic mitral stenosis with evidence of hemolytic anemia. Further, evaluation of the cause of her anemia revealed HS.This case highlights the importance of the evaluation of anemia in patients with valvular heart diseases. If a treatable cause is found, anemia can be treated to reduce the cardiac burden

Infectious mononucleosis with follicular tonsillitis and urinary tract infection

Despite the prevalence of Epstein-Barr virus (EBV) infection, new reports of weird and atypical manifestations of the infection continue to emerge, raising the question of how well we know this pathogen. The clinical appearance of patients who become infected throughout their youth or early adulthood is changing as the infection age rises in developed countries. Other physical symptoms are less noticeable and liver involvement is more noticeable throughout these stages. To inform health-care professionals of this change, an update on infectious mononucleosis variable manifestation is necessary. This case presented a 28-year-old female presented with a history of fever, nausea, and vomiting with odynophagia and cervical lymphadenopathy. Complete blood count and peripheral blood film examination revealed lymphocytic leukocytosis with many reactive lymphocytes. Her monospot test for EBV was positive along with a urine culture positive for Staphylococcus aureus.

Conservation of Indigenous Cattle Breed

India, one of the twelve mega biodiversity countries in the world, is home to large diversified cattle genetic resources, having 190.9 M cattle and so far 43 registered native cattle breeds. These cattle breeds are specially adapted to different agro-climatic conditions of India and their genetic diversity is due to the process of domestication over the centuries. There is decrease of 4.10% in cattle population and 3.14% in cattle genetic resources of India as compared to the quinquennial livestock census. The exotic / crossbred population has been increased by 20.18% during the period of last census while population of indigenous cattle has been decreased by 8.94% during the same duration. The reasons for depletion of native breeds includes crossbreeding with exotic breeds, economically less viable, loosing utility, reduction in herd size and the large scale mechanization of agricultural operation. The native breeds need to be conserved for genetic insurance in future, scientific study, as a part of our ecosystem, cultural and ethical requirements and for energy sources in future. The indigenous breeds of cattle posses various unique characteristics such as the presence of unique genetic variation in HSP70 gene family, carry a ‘thermometer gene’ and presence of A2 allelic variant in cow milk, which makes them well adapted to the tropical climate. The conservation includes the preservation along with up-gradation (improvement) of the genetic potential and management of a breed for use in future. The effective management of indigenous cattle resources includes identification, characterization, evaluation, documentation and conservation. The future strategy should be to combine genetic improvement and conservation. Establishment of regional gene banks and people’s participation by involving breeders, communities, gaushalas, NGOs and other relevant stakeholders in conservation programs. For more effective conservation measures, proper coordination and integration among various agencies (ICAR, SAHD, SAUs, SVUs and Research Institutes) is highly needed. “National Consortium of Partners’ comprising different stakeholders should be formulated for conservation of indigenous breed resources with a holistic approach.

Relationship of nutritional status with tuberculin sensitivity.

Objective. To estimate the prevalence of under- nutrition among school children and to find out the relationship between nutritional status and tuberculin sensitivity. Methods. A cross sectional study was carried out among 3335 children between 5-8 years of age, attending 60 schools in Bangalore city, selected by stratified random sampling. The nutritional anthropometric indices were calculated using reference median as recommended by World Health Organization, classified according to standard deviation units termed as Z-scores. The nutritional status of the children was assessed by weight for age, height for age and bio-mass-index (BMI). Results. Depending upon the method for classifying nutritional status, the prevalence of under-nutrition (including mild and severe under-nutrition) varied between 14.9-29.8%. The prevalence of severe under-nutrition varied from 2.9-6.7%. The frequency distributions of reaction sizes to tuberculin were found to be similar among children classified by nutritional status. The differences in proportions of significant reactions (≥10mm) and mean tuberculin reaction sizes between children classified by nutritional status were not found to be statistically significant. Conclusion. Tuberculin sensitivity was not influenced by nutritional status among apparently healthy school children.

Annual risk of tuberculous infection in Andhra Pradesh, India.

BACKGROUND: There is paucity of information on epidemiological situation of Tuberculosis (TB) in Andhra Pradesh. The DOTS strategy under the Revised National Tuberculosis Control Programme (RNTCP) was introduced in the year 2000 to cover the entire State by 2005. OBJECTIVES: To estimate the prevalence of tuberculous infection among children 5-9 years of age and to compute the average Annual Risk of Tuberculosis Infection (ARTI) from the estimated prevalence. METHODS: A cluster-sample house-based tuberculin survey was carried out in a representative sample of children between 5-9 years of age. The clusters were selected by a two-stage sampling procedure. At first stage, five districts were selected by probability proportional to population size (PPS) method. Depending upon child population ratio, 32 clusters allocated to each district were further sub-divided into rural and urban clusters selected by simple random sampling. A total of 3636 children, irrespective of their BCG scar status, were tuberculin tested using one TU PPD RT23 with Tween 80 and the maximum transverse diameter of induration was measured about 72 hours later. RESULTS: The prevalence of infection estimated by mirror-image technique using observed mode of reactions attributable to infection with tubercle bacilli at 20mm was 9.6% (95% CI: 8.0-11.2). The ARTI was computed at 1.4% (95% CI: 1.1-1.6). CONCLUSION: Survey findings indicate a fairly high rate of transmission of tubercle bacilli.

Triple A syndrome.

Triple A syndrome (Allgrove syndrome) is an autosomal recessive disorder consisting of achalasia, alacrima and Addison insufficiency. We report an 11-year-old girl with predominant symptom of achalasia who was diagnosed as Triple A syndrome almost 3 years after initial presentation.

Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2.

BACKGROUND: The prevalence of risk factors for coronary heart disease has been inadequately studied in India. A repeat cross-sectional survey was carried out to evaluate the changes in the major coronary risk factors in the urban population of Jaipur previously studied in the early 1990s. METHODS AND RESULTS: Randomly selected adults > or =20 years of age were studied using stratified sampling. The target study sample was 1800 with a population proportionate gender distribution (males 960, females 840). Coronary risk factors, anthropometric variables, blood pressure, ECG, fasting blood glucose and lipids were evaluated. A total of 1123 subjects (62.4%) (males 550, females 573) were examined. Fasting blood samples were available in 523 males and 559 females. Overall coronary heart diesase prevalence, diagnosed by history or ECG changes, was found in 34 males (6.18%) and 58 females (10.12%). Risk factor prevalence showed that smoking/tobacco use was present in 201 males (36.5%) and 67 females (11.7%). Physical inactivity, either work-related or leisure time, was seen in 157 males (28.5%) and 130 females (22.7%). Hypertension (> or =140 and/or 90 mmHg) was present in 200 males (36.4%) and 215 females (37.5%). Diabetes diagnosed by history or fasting glucose > or =126 mg/dl was found in 72 males (13.1%) and 65 females (11.3%). Obesity, body mass index > or =27 kg/m2 was present in 135 males (24.5%) and 173 females (30.2%), while truncal obesity (waist:hip >0.9 males, >0.8 females) was found in 316 males (57.4%) and 392 females (68.4%). The most common dyslipidemia in both males and females was low HDL-cholesterol (<40 mg/dl: males 54.9%, females 54.2%). High total cholesterol levels of > or =200 mg/dl (males 37.4%, females 4.1%), high LDL-cholesterol levels of > or =130 mg/dl (males 37.0%, females 45.8%) and high levels of triglycerides > or = 150 mg/dl (males 32.3%, females 28.6%) were also seen in a significant number. Hypertension, obesity, truncal obesity, diabetes and dyslipidemias increased significantly with age in both males and females (Mantel-Haenzel chi2 for trend, p<0.05). CONCLUSIONS: There is a high prevalence of standard coronary risk factors--smoking, physical inactivity, hypertension, hypercholesterolemia, diabetes and obesity--as well as factors peculiar to south Asians--truncal obesity, low HDL-cholesterol and high triglycerides--in this urban Indian population. As compared to a previous study in the early 1900s in a similar population, there is a significant increase in the number of people with obesity, diabetes and dyslipidemias.

Gastro-duodenal mucosal changes associated with low-dose aspirin therapy: a prospective, endoscopic study.

OBJECTIVES: The association of low-dose aspirin use and gastro-intestinal bleeding is well described. However, the gastroduodenal mucosal changes associated with low-dose aspirin therapy have not been properly evaluated. We undertook a prospective, endoscopic study to evaluate gastro-duodenal mucosal lesions produced by low-dose aspirin. METHODS: Forty-seven patients with non-hemorrhagic cerebral infarct or transient ischemic attacks and normal upper gastrointestinal endoscopy were randomized to receive either enteric-coated (n=25) or plain (n=22) aspirin (150 mg/day). Follow-up endoscopy was done at 2, 4 and 8 weeks; gastro-duodenal mucosal lesions, if present, were scored. Forty-seven patients with hemorrhagic infarct who were not treated with aspirin served as controls. RESULTS: Twenty eight (60%) of 47 patients receiving aspirin had mucosal lesions; stomach alone was the most frequent site (32%), followed by both stomach and duodenum (23%). Frequency of mucosal changes in the stomach at 8 weeks (19%) was significantly lower (p<0.05) than those at 2 weeks (53%) and 4 weeks (55%). Coated (56%) and plain (63.6%) aspirin induced mucosal lesions with similar frequency. CONCLUSION: Administration of low-dose aspirin, either plain or enteric-coated, induces endoscopic gastro-duodenal mucosal lesions in a large majority of patients. The frequency of damage decreased after 8 weeks of therapy.

Assessment of utility of Siriraj Stroke Score (SSS) in stroke patients of Pt. BD Sharma PGIMS hospital, Rohtak, India.

India has predominantly poor rural population where brain CT scan, most often advised investigation in patients of stroke, may not always be available, hence Indian physician in such setting base his diagnosis on bed side sign evaluation for which Siriraj Stroke Score (SSS) could be helpful. Objective of study: to assess the utility of SSS in patients of stroke. Methodology: sixty subjects of stroke were evaluated on SSS and 'probable' diagnosis so made was compared with CT scan's (brain) 'certain' diagnosis. Main findings: by using SSS, the probable bedside diagnosis was cerebral infarct (score < -1) in 32 subjects and cerebral haemorrhage (score > +1) in 24 subjects while 4 subjects had indeterminant score (-1 to +1). Fifty subjects had their probable diagnosis matched with brain CT scan certain diagnosis. The above findings showed that SSS had 93.7% sensitivity, 76.6% specificity, 81.2% positive predictive value, 92% negative predictive value with an overall accuracy as 93.7% for diagnosis of cerebral infarction. For patients of cerebral haemorrhage the sensitivity was 83.3%, specificity was 92.5%, positive predictive value was 86.9%, negative predictive values was 92.5% with overall accuracy as 83.3%. Principal conclusion: physicians in the rural settings may find SSS to be quite useful in the management of stroke especially where more sophisticated radiological investigations may not be available for confirmation of diagnosis due to high cost or attended due to transportation risk.

Oxidative stress in gastric mucosa in Helicobacter pylori infection.

BACKGROUND: Infection with Helicobacter pylori is believed to be associated with generation of reactive oxygen molecules which leads to oxidative stress in the gastric mucosa; but the relation between oxidative stress and gastrointestinal mucosal damage has not been documented. AIM: To look for evidence of oxidative stress and lipid peroxidation in the gastric mucosa in H. pylori-associated peptic ulcer. METHODS: 34 duodenal ulcer (DU) patients with H. pylori infection, 14 DU patients without H. pylori infection and 10 healthy subjects without H. pylori infection were studied. H. pylori infection was diagnosed by histology and rapid urease test on endoscopic biopsies from the gastric body and antrum. Reduced glutathione (GSH) and malondialdehyde (MDA) content were measured in biopsies taken from the gastric antrum. Statistical analysis was done using Student's t test. RESULTS: Tissue levels of GSH were significantly lower (91.7 [35.4] nmole/100 mg versus 147.3 [41.2] nmole/100 mg; p < 0.001) and MDA higher (163.0 [83.4] nmole/100 mg versus 109.2 [51.3] nmole/100 mg; p < 0.01) in patients with DU associated with H. pylori infection as compared to those without H. pylori infection. GSH levels were significantly lower and MDA levels higher in DU patients with or without H. pylori infection as compared to control subjects. Serum MDA levels in DU patients with H. pylori infection were also significantly higher than in patients without H. pylori infection. CONCLUSION: Depletion of gastric mucosal glutathione in H. pylori-infected DU patients may be due to failure of the antioxidant defense system. Failure of the glutathione-dependent defense system results in accumulation of free radicals which can initiate membrane damage by lipid peroxidation.

Hepatic manifestations in chronic arsenic toxicity.

OBJECTIVE: The hepatotoxic action of arsenic, when used as a therapeutic agent, has long been recognized. Data on liver involvement following chronic exposure to arsenic-contaminated water are scanty. We report the nature and degree of liver involvement on the basis of hospital-based and cohort follow-up studies in patients who consumed arsenic-contaminated drinking water for 1 to 15 years. METHODS: 248 patients with evidence of chronic arsenic toxicity underwent clinical and laboratory examinations including liver function tests and HBsAg status. Liver biopsy was done in 69 cases; in 29 patients, liver arsenic content was estimated by neutron activation analysis. A cohort follow up of 23 patients who took arsenic-free water for 2-12 years was also carried out. RESULTS: Hepatomegaly was present in 190 of 248 patients (76.6%). Noncirrhotic portal fibrosis (91.3%) was the predominant lesion in liver histology. The maximum arsenic content in liver was 6 mg/Kg (mean 1.46 [0.42], control value 0.16 [0.04]; p < 0.001); it was undetected in 6 of 29 samples studied. Cohort follow-up studies showed elevation of globulin in four cases and development of esophageal varices in one case. CONCLUSION: We report the largest number of patients with liver disease due to chronic arsenicosis from drinking arsenic-contaminated water. Noncirrhotic portal fibrosis is the predominant lesion in this population.

Isolated myoepithelial duodenal hamartoma presenting with upper gastrointestinal bleed.

Myoepithelial duodenal hamartoma, a rare lesion, usually occurs as a part of diffuse gastrointestinal tract polyposis in Peutz-Jegher's and Gardner's syndromes. Solitary duodenal hamartoma in the absence of other manifestations of polyposis syndrome is rare. We report one such patient presenting with massive gastrointestinal bleeding.

Chronic arsenic toxicity in west Bengal--the worst calamity in the world.

Since 1983 large number of people are being encountered with arsenic toxicity due to drinking of arsenic contaminated water (0.05-3.2 mg/l) in 6 districts of West Bengal. Clinical and various laboratory investigations were carried out on 156 patients to ascertain the nature and degree of morbidity and mortality that occurred due to chronic arsenic toxicity. All the patients studied had typical rain drop like skin pigmentation (being inclusion criteria) while thickening of palm and sole were found in 65.5% patients. Other features included weakness (70%), gastro-intestinal symptoms (58.6%), involvement of respiratory system (57.08%) and nervous system (50.6%). Lung function tests showed restrictive lung disease in 53% (9/17) and combined obstructive and restrictive lung disease in 41% (7/17) of patients. Abnormal electromyography was found in 34.8% (10/29) and altered nerve conduction velocity in 34.8% (10/29) of cases. Enlargement of liver was found in 120 cases (76.9%) while splenomegaly in 31.4% cases. Liver function test showed elevated globulin level in 15.8% and alkaline phosphatase in 51.3%, alanine amino transferase (ALT) in 11.8% and aspartate amino transferase (AST) in 27.6% of cases. Evidence of portal hypertension was found in 33.3% patients. Liver biopsy reports of 45 patients showed non-cirrhotic portal fibrosis in 41, cirrhosis in 2 and normal histology in 2 cases. There was no correlation between the quantity of arsenic taken through water and the level of arsenic in hair, nail, liver tissues and the degree of fibrosis. There were 5 deaths of which one had skin cancer. The various non-cancer manifestations which were observed in these patients were much severe than those reported in similar cases in other parts of the world.

Nucleolar organizer regions in neoplastic and non-neoplastic epithelium of the cervix.

Argyrophilic nucleolar organizer regions (Ag NORs) were counted in biopsies from 203 cases of various lesions of the cervix. The mean number of Ag NORs per nucleus was significantly higher in CIN (4.05 +/- 0.04) and malignancy (5.50 +/- 0.65) as compared to squamous metaplasia (1.74 +/- 0.32) and chronic cervicitis (1.54 +/- 0.42). Adenocarcinomas had higher Ag NOR counts compared to other carcinomas. Estimation of Ag NORs can be helpful in distinguishing benign lesions from CIN and malignancy of the cervix.

Needle aspiration in large amoebic liver abscess.

The role of percutaneous needle aspiration for therapy of uncomplicated, large amoebic liver abscess (ALA) is not defined. Twenty nine patients of ALA with a cavity larger than 5 cm were randomised to two groups: (i) metronidazole 800 mg tid for 10 days combined with needle aspiration (group A, n = 15) and (ii) metronidazole therapy alone (group B, n = 14). Clinical parameters, viz, fever, pain and abdominal tenderness were recorded daily and graded 0 to 3 (in order of increasing severity). A statistically significant benefit was demonstrated in group A for clinical parameters evaluated. Group A patients took less time to become afebrile from the grade 2 level as compared to group B (3.8 +/- 1.7 days and 5.6 +/- 2.2 days respectively; p < 0.05). Reduction in pain intensity and abdominal tenderness from grade 2 to 1 also occurred earlier in group A (0.7 +/- 0.7 days vs 2.9 +/- 0.9 days for pain, P < 0.001 and 1.7 +/- 0.8 days vs 2.9 +/- 1.2 days for abdominal tenderness, p < 0.001). The mean duration of hospitalization was significantly shorter in group A as compared to group B (5.8 +/- 0.8 days vs 7.4 +/- 1.5 days, p < 0.001). Improvement in haematological and biochemical variables was similar in both groups. We conclude that percutaneous therapeutic needle aspiration of uncomplicated, large ALA hastens clinical recovery.

Neuroticism and stressful life events in patients with non-ulcer dyspepsia.

Hindi adaptation of the Middlesex Hospital Questionnaire (MHQ), Brief Psychiatric Rating Scale and Presumptive Stressful Life Events Scale were used to measure neuroticism, psychiatric morbidity and stressful life events in 35 patients with non-ulcer dyspepsia (NUD), 22 cass of peptic ulcer disease (PUD), 65 irritable bowel syndrome (IBS) and 45 age and sex matched healthy controls. NUD subjects had significantly higher total MHQ scores (28.8 +/- 11.3; p < 0.001) and scores in subscales of somatization (7.8 +/- 3.4; p < 0.001) and hysterical personality traits (5.5 +/- 2.8; p < 0.01) compared to healthy controls. MHQ scores in IBS subjects was significantly higher than in NUD, but in PUD subjects it was in-between NUD and healthy controls. Psychiatric morbidity, as assessed by Brief Psychiatric Rating Scale, was significantly higher in patients with NUD and IBS than in normal controls. Stressful Life event score was statistically similar in all the groups.

Interaction of organophosphorus insecticides phosphamidon & malathion on lipid profile & acetylcholinesterase activity in human erythrocyte membrane.

The organophosphorus insecticides phosphamidon and malathion were found to inhibit the activity of human acetylcholinesterase in vitro, in the human erythrocyte membrane. Lineweaver-Burk analysis indicated that the insecticide induced inhibition of acetylcholinesterase activity was uncompetitive in nature. The total lipid, cholesterol and phospholipid contents of erythrocyte membranes were reduced following phosphamidon and technical malathion treatment, while the level of lipid peroxidation was raised following malathion treatment.