Evaluation of antibiotic sensitivity pattern in cases of enteric fever in north west Rajasthan.

A total of 50 cases of blood culture proved enteric fever were studied for clinical response to the treatment and compared with in vivo antibiotic sensitivity pattern. Out of 50 Salmonella strains isolated, 37 were S typhi and 13 S paratyphi A. All S typhi isolates were sensitive in vitro to gentamicin and ceftriaxone while sensitivity to ciprofloxacin was 73%, ampicillin 29.7%, chloromphenicol 27%, tetracycline 27% and co-trimoxazole 13.5%. Multidrug resistance (Ampicillin, Chloramphenicol, Cotrimoxazale and Tetracycline) was observed in 62% isolates. All Sparatyphi A isolates were sensitive to all the antibiotics. Clinical response to the antibiotic therapy was as follows: Group I--Ampicillin + Gentamicin: 15 cases, clinical response (CR), 9.1% (S typhi) and 75% (S paratyphi A), mean day of defervescence 5.33 days. Group II--Ciprofloxacin: 29 cases, clinical response 47.6% (S typhi) and 75% (S paratyphi A), mean day of defervescence--5.22 days. Group--III Ceftriaxone: 30 cases, clinical response 100% in all, mean day of defervescence--4.93 days. Thus we observed highly significant discrepancy in antibiotic sensitivity pattern of the isolates and clinical response. Most importantly we observed significantly delayed clinical response to the ceftriaxone. This may be indicative of evolving resistance to ceftriaxone.

Hospital-based case series of 175 cases of serologically confirmed brucellosis in Bikaner.

OBJECTIVE: To study the clinical spectrum of brucellosis in Bikaner (Northwest India). METHODS: A total of 175 cases were diagnosed as brucellosis during the period of six year (June 1997 to May 2003). They were studied for clinical profile and treated by rifampicin and doxycyclin and additionally streptomycin for initial 14 days in patients of neurobrucellosis. These patients were followed up to 3 months. RESULTS: Patients of brucellosis presented with a wide spectrum of clinical manifestations. Out of 175 cases 155 were from rural area. Age ranged between 12-60 years (124 males, 51 females). Analysis of risk factors revealed history of raw milk ingestion (86.86%), occupational contact with animals (81.14%), handling of infected material (62.28%), household contact (16%) and 2 patients were veterinarian. Joint pain (83.43%) and fever (77.71%) were the commonest presenting feature. Sacroiliac joint was most commonly involved (46.86%). 31 cases had involvement of multiple joints. Other mode of presentation were neurobrucellosis (18.86%), manifested as polyradiculoneuropathy, myeloradiculopathy, meningoencephalopathy and polyradiculomyeloencephalopathy; predominant pulmonary involvement (4.0%) presented as bronchitis, pneumonia and pleural effusion; epididymoorchitis, infective endocarditis, nephrotic syndrome and recurrent abortion. All patients responded well to the treatment. CONCLUSION: Brucellosis is an important emerging zoonotic disease but it is often under-diagnosed due to lack of suspicion and diagnostic facilities despite the fact that cattle farming (an important high risk group) is one of the main occupation in rural area. This report should infuse the awareness about this reemerging disease specifically in high-risk group.

Serum magnesium: an early predictor of course and complications of diabetes mellitus.

The aim of this study was to evaluate relationship between serum magnesium and course of diabetes mellitus and also to find out, if there is any relation between serum magnesium and various complications of diabetes mellitus. A cross-sectional study was conducted to examine the relationship between serum magnesium in 50 type 1 and type 2 diabetic patients with or without complications and 40 normal healthy persons. Serum magneisum estimation was done using calmagite dye method using autoanalyser (Beckman DU clin systems). Serum magnesium levels in diabetic population was significantly low (1.93 +/- 0.282 meq/l) in comparison to control (2.25 +/- 0.429 meq/l). It was statistically significant (+3.84; p < 0.005). Serum magnesium was significantly low in diabetes with complication than without complications (p < 0.001). Duration of diabetes and serum magnesium were inversely related. Poor glycaemic control was associated with hypomagnesaemia (-2.623; p < 0.05). There was strong association between hypomagnesaemia and retinopathy (1.76 +/- 0.26), obesity (1.878 +/- 0.326) and hypertension (1.75 +/- 0.071) and it was statistically significantly (p < 0.005, 0.042, 0.000 respectively). Hence it is concluded that the change in serum magnesium level may have a bearing on the complication and morbidity in patients of diabetes mellitus.

A double blind, randomised placebo controlled trial of rifampicin with omeprazole in the treatment of human cutaneous leishmaniasis.

BACKGROUND & OBJECTIVES: This study was conducted on 50 patients of Anthroponotic cutaneous leishmaniasis (oriental sore) to assess the efficacy of rifampicin and omeprazole through a double blind, randomised placebo control study. METHODS: The diagnosis of Anthroponotic cutaneous leishmaniasis (ACL) caused by Leishmania tropica was done by demonstration of Leishmania tropica (LT) bodies from the painless, dry ulcerative lesion. Each patient was assessed clinically in the beginning of the study, at the end of 2,4 and 6 weeks and all observations were compared in both the groups. Twenty-five patients received rifampicin with omeprazole (Group A) whereas other 25 patients received placebo (Group B) for a period of six weeks. RESULTS: Altogether 23 cases in group Aand 21 cases in group B completed the study. About 16 (69.7%) cases in group A and 3 (14.29%) cases in group B had complete healing, whereas 3 patients (13.04%) of group A and 4 patients (19.05%) of group B had partial response and 4 patients (17.93%) of group A and 14 patients (66.67%) of group B had no response at the end of study. The difference of two groups was statistically highly significant (p < 0.00025). All patients tolerated the drug and placebo very well and no side effect was reported. INTERPRETATION & CONCLUSION: In our opinion rifampicin and omeprazole is a highly effective, less toxic and cheaper alternative for the management of cutaneous leishmaniasis.

The changing spectrum of severe falciparum malaria: a clinical study from Bikaner (northwest India).

BACKGROUND & OBJECTIVES: Recently there were reports from all over India about changing spectrum of clinical presentation of severe malaria. The present study was planned to study the same in the northwest India. METHODS: This prospective study was conducted on patients of severe malaria admitted in a classified malaria ward of a tertiary care hospital in Bikaner, Rajasthan (northwest India) during 1994 and 2001. It included adult patients of both sexes belonging to all age groups. The diagnosis of Plasmodium falciparum was confirmed by demonstrating asexual form of parasites in peripheral blood smear. All patients were treated with i.v./oral quinine. The specific complications were treated by standard WHO protocol. The data for individual complications for both the years were analysed by applying chi-square test. RESULTS: In a prospective study in 1994 the spectrum of complication was dominated by cerebral malaria (25.75%) followed by jaundice (11.47%), bleeding tendencies (9.59%), severe anaemia (5.83%), shock (5.26%), Acute respiratory distress syndrome-ARDS (3.01%), renal failure (2.07%) and hypoglycemia (2.07%) whereas in 2001 it was dominated by jaundice (58.85%) followed by severe anaemia (26.04%), bleeding tendencies (25.52%), shock (10.94%), cerebral malaria (10.94%), renal failure (6.25%), ARDS (2.08%) and hypoglycemia (1.56%). The sharp difference for presence of jaundice and severe anaemia in 2001 and cerebral malaria in 1994 was statistically significant. Similarly, the important cause of mortality in 2001 was multiple organ dysfunction syndrome (71.10%) with predominant presentation of jaundice and renal failure, whereas in 1994, it was cerebral malaria (77.96%). INTERPRETATION & CONCLUSION: The observation of changing spectrum of severe malaria in this study and a significant increase in presentation with jaundice as an important manifestation is highly essential for primary, secondary and tertiary level health care providers for proper diagnosis and management.

A comparative study of regression of jaundice in patients of malaria and acute viral hepatitis.

BACKGROUND & OBJECTIVES: Jaundice is one of the common manifestations of severe malaria in adults. The purpose of this study is to compare the pattern of clinical and biochemical parameters such as serum bilirubin and liver enzyme levels in patients of malaria with jaundice and acute viral hepatitis. METHODOLOGY: The present study was conducted on 34 patients of malaria with jaundice and 15 patients of acute viral hepatitis. Estimation of serum bilirubin, aspartate amino transferase (AST), alanine amino transferase (ALT) and alkaline phosphatase was done daily using standard procedures in malaria patients and weekly in acute viral hepatitis patients. RESULTS: Mean level of serum bilirubin on first day in malaria and acute viral hepatitis patients was 7.07 +/- 3.94 and 10.38 +/- 7.87 mg%, whereas on Day 8 it was 1.19 +/- 1.43 and 7.88 +/- 7.02 mg% respectively. Mean level of AST on Day 1 in malaria and acute viral hepatitis patients was 158.47 +/- 120.35 and 1418.6 +/- 834.11 IU/L, whereas on Day 8 it was 41 +/- 28.33 and 775.3 +/- 399.01 IU/L respectively. Mean level of ALT on Day 1 in malaria and acute viral hepatitis patients was 220.14 +/- 145.61 and 1666.67 +/- 1112.77 IU/L, whereas on Day 8 it was 50.85 +/- 37.31 and 823.8 +/- 475.06 IU/L respectively. Mean level of serum alkaline phosphatase on Day 1 in malaria and acute viral hepatitis patients was 394.74 +/- 267.78 and 513.4 +/- 324.7 IU/L, whereas on Day 8 it was 84.76 +/- 68.50 and 369.27 +/- 207.75 IU/L respectively. INTERPRETATION & CONCLUSION: We observed that resolution of jaundice in malaria took 1-2 weeks in contrast 6 to 8 weeks in viral hepatitis. This difference in duration was statistically significant. Thus, jaundice not resolving in 1-2 weeks time in a patient of malaria requires serious consideration for presence of other concomitant diseases including viral hepatitis.

Extraintestinal manifestations of idiopathic ulcerative colitis in northwestern India.

OBJECTIVE: To determine the frequency of extraintestinal manifestations in patients with idiopathic ulcerative colitis. METHODS: 46 patients underwent detailed clinical, biochemical and radiological evaluation. RESULTS: One patient (2%) had peripheral arthritis and two patients (4%) had ocular involvement in the form of anterior uveitis. No patient had mucocutaneous, vascular, or hepatobiliary manifestations, or sacroiliitis. CONCLUSIONS: The frequency of extraintestinal manifestations in patients with IUC in northwestern India is low.

Malarial hepatitis.

AIMS AND OBJECTIVE: To study the clinical, biochemical and histopathological changes in the liver of patients of Plasmodium falciparum malaria with jaundice. MATERIAL AND METHOD: This study was conducted on 50 PBF confirmed cases of Plasmodium falciparum malaria with jaundice. Detailed history, clinical examination, biochemical parameters for liver function test and blood for hepatitis B and C was done in all patients. Liver biopsy was done for detailed histopathological examination in all the 20 patients having serum bilirubin between 3 to 10 mg%. All patients were treated by IV/oral quinine using standard regimen. RESULTS: Age of the patient was ranging from 15-45 years. All patients had jaundice, 70% had pallor, 56% had splenomegaly, 48% had hepatomegaly and 24% of cases had coma. Based on serum bilirubin level, the patients were categorized in group A (18 patients, serum bilirubin < 3 mg%), in group B (20 patients, serum bilirubin 3-10 mg%) and in group C (12 patients, serum bilirubin >10 mg%). Histopathological examination done in all the 20 patients of group B, showed evidence of swollen hepatocytes (100%), malarial pigment deposition (75%), inflammatory infiltrates (60%), congestion of hepatocyte (50%) alongwith centrizonal necrosis in 25% of cases. CONCLUSION: The evidence of predominant conjugated hyperbilirubinemia, increased levels of AST and ALT along with evidence of hepatocellular necrosis in histopathological examination are strong evidence of gross hepatocytic dysfunction in patients of Plasmodium falciparum malaria with jaundice. Therefore the term malarial hepatitis should not be taken as a misnomer.

Pulmonary manifestations in brucellosis: a report on seven cases from Bikaner (north-west India).

OBJECTIVES: Pulmonary manifestations of Brucellosis are rare. We came across seven patients with predominant symptomatology of pulmonary involvement amongst 98 patients of active brucellosis seen in last four years. MATERIAL AND METHODS: The study is related to patients of brucellosis whose principal presenting features were related to respiratory symptom (cough, expectoration, pain in chest and breathlessness) along with fever and other constitutional symptoms. It included seven patients amongst 98 patients of active brucellosis seen during June 1996 to Feb. 2000 at PBM Hospital Bikaner. Diagnosis was confirmed by demonstration of the raised brucella agglutination titre of 1:320 or more in the serum. All patients were treated with rifampicin 900 mg daily and doxycyclin 100 mg twice daily for six week. The treatment was extended for another four weeks in two patients because of persistence of skiagram abnormalities. RESULT: Three patients had abnormality in skiagram chest in the form of pleural effusion, multiple paranchymal opacities and pneumonia. The skiagram chest was normal in remaining four patients. The response of treatment started with 10-15 days and all the patients became symptom-free at the end of six weeks except one patient. Skiagram chest at this time was normal in patients of pleural effusion but there was persistence of haziness and few opacities in other two patients. Follow up skiagram chest at the end of six months and twelve months was normal in all patients except calcified opacity in one patient. There was no evidence of relapse in any patient at the end of one year follow up. Liver function tests remained within normal range and no drug toxicity was observed. CONCLUSION: Pulmonary manifestations of brucellosis are rare. Treatment with rifampicin and doxycylin showed marked clinical and radiological improvement. All patients were completely disease-free at the end of one year follow up.

Scorpion envenomation causing hemiparesis.

We report a case of scorpion sting who presented with right hemiparesis and deranged level of consciousness. Prolonged BT/CT, decreased platelet counts, prolongation of PT and APTT with positive fibrinogen degradation products (FDP) D-dimer and CT scan findings of multiple cerebral haemorrhagic infarct indicating the presence of disseminated intravascular coagulation (DIC) as a cause of hemiparesis. Patient was managed with fresh blood transfusion and conventional treatment with favourable outcome.

A randomized placebo controlled trial of Inolter (herbal product) in the treatment of type 2 diabetes.

OBJECTIVE: To evaluate the safety and effectiveness of Inolter in achieving glycemic control and changes in lipid profile of newly diagnosed type 2 diabetics. MATERIAL AND METHODS: Study design: A randomized, placebo-controlled double blind. Sixty newly diagnosed patients of type-2 diabetes were randomized. Of these, 30 were put on Inolter monotherapy and 30 patients on placebo. Efficacy of Inolter was determined by observing glycemic control by estimating glycosylated haemoglobin (HbA1c) and fasting blood sugar (FBS), alteration of lipid profile by serum cholesterol, LDL, VLDL, HDL and triglycerides. STATISTICAL METHODS: Student's unpaired 't' test. RESULTS: Patients compliance was satisfactory and no adverse effects were observed. Better hypoglycemic effect was observed with Inolter both respect to fasting blood sugar (mean 65.4 +/- 63.72 mg/dl) compared to placebo (mean 26.45 +/- 38.3 mg/dl) (p < 0.001). The mean change, with Inolter, in serum cholesterol (21.33 +/- 26.05 mg/dl), serum triglyceride (30.36 +/- 32.62 mg/dl), VLDL (8.85 +/- 3.25 mg/dl), LDL (10.00 +/- 4.48 mg/dl) and HDL (-2.33 +/- 5.66 mg/dl) was also significantly different (p < 0.001) from those given placebo, where it was 15.7 +/- 20.14 mg/dl, 8.70 +/- 13.24, 0.10 +/- 4.10 mg/dl, -0.70 +/- 4.58 mg/dl and 0.65 +/- 0.00 mg/dl, respectively. CONCLUSION: Inolter appears to be an useful adjunctive therapy to exercise and diet control in newly diagnosed type 2 diabetes mellitus.

Cerebral malaria in Indian adults: a prospective study of 441 patients from Bikaner, north-west India.

AIMS OF THE STUDY: As per WHO (1993) the assessment and analysis of local problems and an appropriate epidemiological information system is an essential part of a control programme before embarking any control activity. METHODOLOGY: Four hundred and fourty one (441) adults of strictly defined admitted cerebral malaria patients were studied. Detailed clinical/neurological examination was done at the time of admission, daily thereafter, at the time of regaining consciousness, at the time of discharge and at weekly intervals in those having neurological sequelae. All patients were treated by i.v./oral quinine and specific syndromes were managed according to WHO guidelines. RESULTS: Apart from fever and unconsciousness in all the patients, other features were convulsion (21.31%), neck rigidity (19%), psychosis (5.21%), conjugate deviation of eyes (2.26%), extrapyramidal rigidity (2.25%), trismus (1.31%), decorticate rigidity (1.13%) and decerebrate rigidity (0.90%). One hundred forty five (32.87%) patients expired and mortality was highest in pregnant ladies (39.28%). The important neurological sequelae in survivors were psychosis in 15 (5.06%), cerebellar ataxia in 14 (4.72%), hemiplegia in five (1.68%), extrapyramidal rigidity (EPR) in four (1.35%), peripheral neuropathy in three (1.01%), EPR with trismus in one (0.33%) and isolated sixth nerve palsy in one (0.33%) patients and all showed complete recovery in further follow up. CONCLUSION: The important observations of this study were stormy presentation, increased incidence of haemoglobinuria and jaundice, presence of neck rigidity, no prognostic relation to fundus abnormalities and high incidence of cerebellar ataxia and psychosis as neurological sequelae in survivors. Knowledge of self-limiting course of neurological sequelae may be helpful in reducing economic strain of expensive investigations and treatment.