Ophthalmic manifestations of Dengue Fever

Objective: To describe the clinical spectrum of ophthalmic manifestations in patients presenting with dengue fever during the outbreak at Lahore in autumn of 2011

Study Design: Prospective study

Place and Duration of Study: Combined Military Hospital Lahore, from Sep 2011 to Dec 2011

Material and Methods: This prospective study was conducted at CMH Lahore. Al most 3005 clinical dengue cases were recruited for the study from 39930 cases that reported at OPD with suspected dengue fever. All these patients were screened for ophthalmic involvement. These patients were subjected to serological analysis for detecting dengue specific IgM antibodies [IgM enzyme-linked immunoassay] and blood test for thrombocytopenia after taking written informed consent. The patients with ophthalmic involvement were subjected to detailed history, ocular examination including anterior and dilated posterior segment examination. Ophthalmic manifestations in these patients were recorded and tabulated according to the frequency

Results: The study showed that dengue fever could result in a variety of ocular complications. Majority of these complications were innocuous and self limiting. Most common is subconjunctival haemorrhage. Other includes retrobulbar haemorrhage, proptosis, increased IOP, vitreous haemorrhage, retinal haemorrhage and peri ocular ecchymosis. Vision threatening complications were seen in only 1 Percent of cases

Conclusion: Dengue fever can result in a range of ocular complications so ophthalmic examination should be performed in patients presenting with all forms of the disease. The most common is sub-conjuntival haemorrhage. The vision threatening complications among these occur with involvement of posterior segment including vitreous and retinal haemorrhages. This justifies detailed fund us examination of these patients with a dilated pupil

Comparison of central corneal thickness in pseudoexfoliation glaucoma patients with healthy adults

Objective: To compare the central corneal thickness [CCT] in pseudoexfoliation glaucoma [PXG] patients with healthy adults

Study Design: Cross-sectional comparative study

Place and Duration of Study: Armed Forces Institute of Ophthalmology Rawalpindi, from Dec 2009 to Feb 2011

Material and Methods: 30 patients having PXG [Group A] and 30 healthy adults having normal intraocular pressure [Group B] were included in the study. Intraocular pressure [IOP] in both groups was measured using gauged Goldmann applanation tonometer [GAT].Central corneal thickness [CCT] was measured with an ultrasonic pachymeter

Results: The comparison of Mean CCT in both Groups showed that Mean CCT was significantly lesser [17-value <0.05] in PXG Group [519.73 tim] as compared to healthy adults Group [567.48 fim]

Conclusion: CCT in PXG patients group was found to be statistically significantly thinner as compared to healthy adults Group. CCT must be assessed in patients with pseudoexfoliation syndrome [PXF] in order to avoid the underestimation of IOP

IgA nephropathy - its seasonal variation and clinico pathological profile in local patients

To study the frequency of IgA nephropathy in relation to seasonal variation and its clinico-pathological profile at Military Hospital Rawalpindi. A descriptive study. Military Hospital, Rawalpindi, Pakistan from Jan 2010 to Mar 2012. The study was conducted at Military Hospital Rawalpindi on 289 consecutive renal biopsy specimens. Ultrasound

Comparison of real time polymerase chain reaction with microscopy and antigen detection assay for the diagnosis of malaria

To determine the sensitivity of a real time polymerase chain reaction [PCR] for malaria diagnosis and to compare its accuracy with microscopy and an antigen based rapid diagnostic test [OptiMal]. Cross-sectional analytical study. Military Hospital, Armed Forces Institute of Transfusion and Armed Forces Institute of Pathology, Rawalpindi, from July to December 2011. Venous blood samples of 300 clinically suspected patients of malaria were tested for malaria parasite by microscopy and OptiMal; and malaria parasite index was calculated for the positive samples. Plasmodium genus specific real time PCR was performed on all specimens, targeting small subunit rRNA gene. Diagnostic accuracy of three tests was compared and cost analysis was done. Out of 300 patients, malaria parasite was detected in 110, 106 and 123 patients by microscopy, OptiMAL and PCR respectively. Real time PCR was 100% sensitive while microscopy and OptiMal had sensitivity of 89.4% and 86.2% respectively. All methods were 100% specific. The cost per test was calculated to be 0.2, 2.75 and 3.30 US$ by microscopy, OptiMal and PCR respectively, excluding the once capital cost on PCR equipment. Genus specific real time PCR for the diagnosis of malaria was successfully established as a highly sensitive and affordable technology that should be incorporated in the diagnostic algorithm in this country.

Valsalva maculopathy

Valsalva retinopathy is a rare condition characterized by preretinal haemorrhage in patients with H/O increased intrathoracic pressure caused by forceful exhalation against a closed glottis. We are presenting a case of a young male adult who developed bilateral valsalva retinopathy following strenuous exercise

Examination of his fundus revealed a round, circumscribed bright-red mound of blood over both maculae

The extent of the lesion in left eye was lesser than the right eye. He was managed conservatively and showed remarkable visual recovery with return of vision to normal in both eyes after 12 weeks

out break of more than 1300 cases of acute viral hepatitis in a tertiary care hospital in Rawalpindi in summer of 2009

To find out the short-term clinical course including common clinical features, laboratory parameters, treatment provided and outcome of cases of acute viral hepatitis hospitalized in a tertiary care hospital. Descriptive observational study. Military Hospital in Rawalpindi from May to July 2009. Patients hospitalized with acute viral hepatitis, both male and female, older than 12 years of age were included in the study. A detailed proforma including patients' particulars, clinical features; laboratory parameters, treatment provided, disposal/ outcome was designed and filled for each patient. During the study period a total 1334 patients were hospitalized, 1279 [95.87%] were male while only 55 [4.13%] were female. Majority of patients were young adults. Mean age was 26 years with a range of 12 to 85 years. Maximum serum bilirubin levels of 559 micromoles /I and serum alanine aminotransferase [ALT] levels of 7750 IU/L were observed. Maximum prothrombin time [PT] ranged from 105 seconds to failed to clot, against a control of 13 seconds. Thrombocytopenia was observed in some patients especially those with coagulopathy and encephalopathy but recovered with improvement in LFTs. Anti HEV serology was sent in a third of all admitted patients and was positive for IgM in patients tested. Five patients were pregnant ladies. Two patients also had laboratory proven malaria along with acute viral hepatitis. Majority of patients had uneventful recovery. A total of 13 patients went in to hepatic encephalopathy while three unfortunate patients died. HEV has been an important cause of acute viral hepatitis in Pakistan, particularly in adults from lower socioeconomic groups. The problem is more serious for those living in military camps, residential institutions and in segregated areas who consume untreated water from a common source. Outbreaks like the one described have significant morbidity and not ignorable mortality for the affected persons

Efficacy of chloroquine monotherapy against plasmodium vivax malaria

To determine the in vivo efficacy of chloroquine monotherapy against Plasmodium [P.] vivax and frequency of relapse/reinfection. Quasi-experimental study. Place and duration of study: Department of Medicine, Combined Military Hospital, Quetta Balochistan, from July 2006 to February 2007. One hundred and ninety one subjects with positive plasmodium vivax slide were included in the study. Mean, median, minimum and maximum values along with standard deviation of age and parasite clearance time were calculated. Frequency of relapse/reinfection was estimated and significance was determined by applying test of significance. Of the 191, 21 developed P.vivax relapse/reinfection in the six months follow up. Mean duration of relapse/reinfection was 37.76 days while mean parasite clearance time was almost 30 hours in both initial infection and relapse. Chloroquine monotherapy is still effective in the management of P.vivax malaria in our set up and antirelapse therapy is not routinely indicated

Brachiobasilic fistula with anterior transposition, a workable solution in difficult clinical situations

This study was undertaken to assess the role of brachio-basilic fistulae with anterior transposition in patients with unsuitable veins for formation of conventional AV fistulae or after failure of multiple fistulae. Descriptive study. Armed Forces Institute of Urology and Military Hospital Rawalpindi, from November 2007 to October 2009. Patients of CKD with unsuitable veins for the formation of conventional AV fistula and those with failed Radiocephalic and Brachiocephalic fistulae in whom Brachio-basilic fistula was formed, were included in the study. Patients unfit for general anesthesia and those with upper arm Prosthetic grafts were excluded. The patients were interviewed, examined with particular attention to vascular access and a complete data about their hemodialysis and previous vascular access was collected. Transposed Brachio-basilic fistulae were created in 38 patients of End Stage Renal Disease [ESRD] during study period; out of which 1 patient was lost during followup and the rest 37 were followed prospectively. The median duration of follow-up was 13.56 months [SD +6.03] with a range of 3 to 23 months. In 92% of cases transposed Brachio-basilic fistula was created after failure of one or more conventional fistulae. Complications were noted in 16.2% cases which included primary failure, wound infection, arm swelling and distal ischemia as a result of steal phenomena [Table]. Three patients died during this period. Life of fistulae ranged from primary failure to as long as 23 months. Transposed brachio-basilic fistula is a viable option for patients who do not have suitable vasculature for formation of conventional fistula but especially for those after failure of fistulae at other sites

Hyperkalemia - frequency in a group of hypertensive diabetics

To evaluate the frequency of hyperkalemia in a cohort of hypertensive diabetic patients. A prospective analytical cohort study. The study was carried out in department of medicine [nephrology] Military Hospital [MH] and Armed Forces Institute of Urology [AFIU] Rawalpindi from Jun 2007 - Jun 2009. A total of 110 hypertensive, middle aged diabetic patients attending medical OPD in MH and AFIU. Rawalpindi were followed over two years from Jun 2007 - Jun 2009 for development of hyperkalemia and monitored for changes in eGFR, Serum Urea, creatinine and blood glucose random besides changes in blood pressure and ECG findings. SPSS version 13 was employed for statistical analysis. During the course of study 9 patients were lost to follow up. There were 7 deaths among study subjects before the end of study after about ten to twelve months. Out of the 94 patients followed up mean Serum Urea at the end of study was 13.50 mmol/l against a serum creatinine level of 2.26mmol/l and an estimated GFR of 21.08 ml/ min. The frequency of raised serum Potassium of 5.1-6.0 mmol/l was 46.08% and 26.59% of the patients had serum Potassium of 6.1-7.2 mmol/l at the end of study. This was against an initial level of 4.5-5.0 mmol/l in 100% of the study subjects. Paired sample t-test revealed significant changes in each variable studied but a borderline positive correlation of 0.619 was observed only between serum potassium and change in eGFR at the end of study. The mean blood glucose random dropped from 16.14 mmol/l to 10.41 mmol/l. at the end of study mean systolic BP was 122mm Hg and diastolic BP 80.2mm Hg. The ECG revealed tall T waves in 64.9% of cases while at the start of study all subjects had their electrocardiograms within normal limits. There was a trend of increase in frequency of tall T waves with the rise of serum potassium levels. Raised serum potassium is a significant potential complication among long standing diabetics with covert nephropathy treated with ACE inhibotrs, ARBs, potassium sparing diuretics or a combination of these drugs. Co morbidities and development of this complication must therefore be considered by physicians when dealing with such patients

Monitoring the biochemical effect of haemodialysis in the patients with end-stage renal disease using saliva as an alternative to serum

To compare the effect of haemodialysis on biochemical changes in saliva with changes in serum in patients with end- stage renal disease [ESRD]. This is a Quasi-experimental study, which was conducted in the Department of Pathology and Nephrology, Army Medical College, Rawalpindi, Pakistan from Sep 2008 to Dec 2008. Total thirty nine patients of ESRD consisting of 28 males and 11 females on maintenance haemodialysis were included by convenient sampling technique. Pre and post haemodialysis 3 ml blood samples and saliva were collected under sterile conditions. Biochemical analysis of urea, creatinine and uric acid were carried out on clinical chemistry autoanalyser Selectra E. Electrolytes were analyzed on ion selective electrode analyzer Easylyte. Serum and salivary nitrite were estimated by Griess reaction on ELISA reader. The results were analyzed on SPSS version 16.0. The patients' age ranged from 15 to 80 years. The causes of ESRD were hypertension 15 [38%], diabetes mellitus 7[18%], pyelonephritis 6[15%], glomerulonephritis 3[8%], nephrolithiasis 3[8%] miscellaneous 2[5%] and unknown 3[8%]. The post dialysis serum and saliva revealed a significant decrease in urea [35.48% vs 30.54%], creatinine [37.48% vs 29.65%], uric acid [44.33% vs 37.51%] and nitrites [67.47% vs 52.00%] [P<0.001]. The study demonstrated significant Pearson's correlation between serum and salivary [pre and post dialysis] urea [r=0.73;p<0.001; r=0.69;p<0.001], creatinine [r=0.83;p<0.001; r=0.72;p<0.001], uric acid [r=0.69;p<0.001; r=0.64;p<0.001] and nitrite [r=0.59;p<0.001; r=0.53;p<0.001] respectively. The study demonstrated significant parallel decrease in urea, creatinine, uric acid and nitrite in the post dialysis samples of serum and saliva. Saliva offers an alternative to serum as a biological fluid that can be analyzed in the laboratory for monitoring biochemical change in the patients of ESRD

Relationship between fibrosis score and response to interferon alfa and ribavirin combination therapy in chronic HCV infection

To compare the response to Interferon Alfa [IFN] and Ribavirin [RBV] combination therapy in patients of chronic HCV infection with fibrosis stage 1 [F1] and stage 2 [F2] with fibrosis stage 3 [F3] and stage 4 [F4]. Quasi-experimental study. Military Hospital, Rawalpindi, from Jan 2004 to Jun 2004. Forty patients of chronic hepatitis C were selected on the basis of raised ALT, presence of anti-HCV antibodies, detection of viral RNA on PCR and liver biopsy. They were divided into 2 groups on the basis of stage of fibrosis. Group A constituted 20 patients with fibrosis stage 1 and 2 and group B constituted 20 patients with fibrosis stage 3 and 4. Interferon Alfa 03 Million units subcutaneously three times a week and Ribavirin 1200 mg orally per day in divided doses for patients who weigh 75 kg and 1000 mg for those weighing less than 75 kg for six months was administered. Polymerase chain reaction [PCR] for HCV RNA was performed at 0 and 6th months at Armed Forces Institute of Pathology Rawalpindi. At completion of treatment, HCV-RNA levels in serum were not detectable in 14 of 20 [70%] patients in group A as compared to 07 of 20 [35%] patients in group B who received interferon alpha and ribavirin combination therapy. Patients with early fibrosis on liver biopsy have better response to IFN- Ribavirin therapy compared to patients with advanced fibrosis

Effect of antiviral therapy on hematological parameters in patients with chronic hepatitis

To find out the effect of antiviral therapy on hematological parameters in patients of chronic hepatitis. Interventional descriptive study. Military hospital [MH] Rawalpindi Pakistan from May to Oct 2004. 31 patients admitted to M.H Rawalpindi for treatment of chronic hepatitis were studied. Their hematological parameters including Total Leucocyte count [TLC], Haemoglobin [Hb] and Platelet count [Plt] were recorded before starting antiviral therapy and then at 3 monthly intervals. All the patients were given Inj Alpha-Interferon [INF] and Tab Ribavirin as antiviral therapy. Data was collected over a period of 6 months. Descriptive statistics were applied to the recorded data using SPSS ver-10.0 for analysis. 31 patients with mean age +/- SD 38.58 +/- 8.85 years [range 16-49 years] were studied. There was mean hemoglobin [Hb] fall of 0.87g/dl at 3 months and 2g/dl at 6 months of antiviral therapy. Mean Total leukocyte count [TLC] fall of 1.30x10[9]/L at 3 months and 1.87x109/L was noted at 6 months. Similar downward trend was noted in Platelet [Plt] values with mean fall of 23.19x10[9]/mm[3] and 28.29/ mm[3] at 3 and 6 months of antiviral therapy respectively. 10% of the cases developed clinically significant anemia as evidenced by hemoglobin 11g/dl after 6 months of antiviral therapy. Clinically significant leucopenia [< 2.5x10[9]/l] was noted in 7% of the cases. This fall was noted only in first three months of treatment. There is significant decrimental response of hematological parameters to antiviral therapy