Enteric fever in an HIV/AIDS patient: atypical manifestations

Bloodstream infections with Salmonella typhi, is uncommon in human immunodeficiency virus [HIV]-infected persons. The symptoms in such patients are often non-specific and have a rather insidious onset and progression. We report a patient with sepsis and lower limb gangrene due to Salmonella typhi infection in an HIV-infected patient.

Ophthalmomyiasis: Three cases from North India.

Three cases of external ophthalmomyiasis are reported here. The larvae were identified to be Oestrus ovis in two cases and Cochliomyia hominivorax in one. Two of the patients were immunocompetent while one was undergoing treatment for squamous cell carcinoma of eyelid. In the latter myiasis led to complete destruction of the eye.

Study of occupational exposure to insecticides while spraying in cotton farms.

Organophosphorus compounds (OPC) are commonly used in farms and agricultural fields as insecticides. This study deals with manifestations of exposure among 40 workers engaged in the spraying of cotton crops with these insecticides over a period of two months. The compounds used were mostly monocrotophos, acephate, chlorpyriphos, methyl parathion and propanophos. All patients were illiterate males in the range of 15 years to 50 years of age. They showed typical manifestations of OPC poisoning. All of them responded to conventional treatment for OPC poisoning. There was one death. During the course of the survey it was found that none of the farmers were using protective gear as mandated by chapter VIII of Insecticides Rules, 1971 (Insecticides Act, 1968). A few of these workers were exposed to the insecticide for as much as nine hours per day for three days. In practice, in some deaths associated with OPC poisoning, history of inhalation is given. It is important to note that this could change the manner of death from suicidal to accidental. Due precaution must therefore be exercised in such cases before opining on the manner of death. It is imperative that extensive and persistent farmer education is done with regard to the implementation of various provisions under the Insecticides Rules, 1971, especially safety issues.

Mass illness due to datura poisoning: A case report.

This report concerns an incident of multiple non-fatal poisonings due to datura, which was mixed in sweetmeat disguised as "prasad". The accused wished to kill his mother-in-law, but the "prasad" was consumed by many others also, who suffered from the manifestations of datura poisoning. However they responded well to routine treatment, and there were no fatalities.

Identification of lysine positive non-fermenting gram negative bacilli (Stenotrophomonas maltophilia and Burkholderia cepacia complex).

BACKGROUND: The Burkholderia cepacia complex (BCC) and Stenotrophomonas maltophilia are closely related groups of non-fermenting gram-negative bacilli (NFGNBs) having a similar spectrum of infections ranging from superficial to deep-seated and disseminated infections. Identification of these lysine decarboxylase-positive NFGNBs lags behind in most Indian laboratories. A simplified identification scheme was devised for these two pathogens that allowed us to isolate them with an increasing frequency at our tertiary care institute. MATERIALS AND METHODS: A simple five-tube conventional biochemical identification of these bacteria has been standardized. In the beginning, some of the isolates were confirmed from the International B. cepacia Working group, Belgium. Molecular identification and typing using recA polymerase chain reaction-restriction fragment length polymorphism was also standardized for BCC. For short-term preservation of BCC, an innovative method of preserving the bacteria in Robertson's cooked medium tubes kept in a domestic refrigerator was developed. RESULTS: Thirty-nine isolates of BCC isolates were obtained from various specimens (30 from blood cultures) and 22 S. maltophilia (13 blood cultures and 9 respiratory isolates) were isolated during the year 2007 alone. CONCLUSIONS: BCC and S. maltophilia can be identified with relative ease using a small battery of biochemical reactions. Use of simplified methods will allow greater recognition of their pathogenic potential and correct antimicrobials should be advised in other clinical laboratories and hospitals.

Heart rate variability in dilated cardiomyopathy.

Chronic heart failure is associated with excessive neurohormonal activation. Analysis of heart rate variability is considered a valid technique for assessment of the autonomic balance of the heart. Twenty symptomatic patients of dilated cardiomyopathy in NYHA class II-IV symptomatic status and as many normal controls were subjected to 24 hours Holter monitoring to assess the heart rate variability with both time domain and frequency domain analysis. Age of the patients ranged from 12 to 67 years (mean +/- SD 38.6 +/- 7 years), the male-female ratio was 4:1. The left ventricular ejection fraction of the patients was between 18-42 percent (mean +/- SD 30.2 +/- 9%) and all received diuretics, digoxin and angiotensin-converting enzyme inhibitors. Heart rate variability parameters measured included mean heart rate with standard deviation, hourly heart rate with SD and the mean of all normal RR intervals from the 24-hour recording. Time domain measures calculated were SD of all normal RR intervals, SD of 5 minute mean RR intervals and root mean square of difference of successive RR intervals. Using spectral plots, frequency domain subsets of low frequency and high frequency were analysed and expressed in normalised units. Total power was also measured. In the dilated cardiomyopathy patients, mean 24-hour heart rate in beats per minute was significantly higher in comparison to controls (82 +/- 13 vs 72 +/- 8; p < 0.001) whereas mean hourly heart rate with standard deviation (msec) was significantly lower (97 +/- 41 vs 232 +/- 25; p < 0.001), SD of all normal RR intervals (msec) was 85.5 +/- 26.3 vs 139.4 +/- 16.9 in controls (p < 0.001), SD of 5 minute mean RR intervals (msec) was also significantly less in patients in comparison to controls (75.8 +/- 39.6 vs 130.8 +/- 20.3; p < 0.001). However, although root mean square of difference of successive RR intervals (msec) was reduced in patients (30.1 +/- 9.3 vs 37.3 +/- 11.7; p < 0.05), the difference was non-significant. Low frequency power (0.05-0.15 Hz) (normalised units) was reduced in the dilated cardiomyopathy group (0.0721 +/- 0.003 vs 0.136 +/- 0.047 in the control group; p < 0.001). High frequency power (0.35-0.50 Hz) (normalised units) (0.08 +/- 0.05 in patients vs 0.09 +/- 0.02 in controls; p > 0.1) and total power frequency (0.02-0.50 Hz) (normalised units) (0.34 +/- 0.05 in patients vs 0.35 +/- 0.12 in controls; p > 0.1) was non-significantly different in the two groups. Regression analysis showed a significant decrease in SD of all normal RR intervals, SD of 5 minute mean RR intervals, low frequency, high frequency, total power and a non-significant decrease in root mean square of difference of successive RR intervals with a decrease in ejection fraction percent whereas there was a significant decrease in SD of all normal RR intervals, SD of 5 minute mean RR intervals, low frequency and total power and a less significant decrease in root mean square of difference of successive RR intervals and high frequency power with an increase in NYHA class. At 6 months duration, 6 patients were lost to follow-up, 3 patients were readmitted (2 for congestive cardiac failure, one of paroxysmal supraventricular tachycardia). One patient who was NYHA class IV at baseline was readmitted for congestive cardiac failure and showed much lower heart rate variability parameters compared to the average of the patients. We conclude that in symptomatic dilated cardiomyopathy patients, heart rate variability parameters are significantly reduced in comparison to control subjects.

Follow-up results of balloon angioplasty for native coarctation of aorta.

Balloon angioplasty of native discrete (< 1 cm) coarctation of thoracic aorta was performed in 29 patients [aged 13 to 31 years (mean 21.5 +/- 5.8 years), 22 males and 7 females], from March 1993 to December 1995. The patients were followed up for two years. After angioplasty, peak systolic arterial pressure (PSAP) decreased from 173.5 +/- 18.1 mm Hg to 122.5 +/- 9.9 mm Hg (p < 0.001), peak systolic pressure gradient (PSG) decreased by 90.9 percent from 86.2 +/- 15.77 to 7.77 +/- 3.8 mm Hg (p < 0.001) and the coarcted segment diameter increased about three times from 3.7 +/- 1.6 to 10.9 +/- 3.3 mm (p < 0.001). PSG decreased to < 10 mm Hg in 27 patients (93%) whereas in the other two patients PSG was 17 and 13 mm Hg. Restenosis appeared in 2 patients (6.8%); aneurysm in one patient (3.4%) which remained static even after 1.3 years of follow-up; mild dissection in 3 patients (10.3%); temporary femoral artery occlusion in 2 (6.8%) patients who recovered with heparin injection. Though hypertension disappeared after balloon dilatation in all patients, it reappeared in 3 patients (10.3%) within 7 days and in 10 patients (34.5%) within 6 months. In conclusion, balloon angioplasty of CoA is a good alternative to surgical correction.

Studies on prosthetic valve function--a transesophageal echocardiographic assessment.

Haemodynamic assessment was done by colour flow mapping and Doppler interrogation by both Transthoracic (TTE) and Transesophageal echocardiography (TEE) in 40 consecutive patients (mean age 36.6 +/- 12.35 years) with prosthetic valves. There were 30 cases of mitral (MVR) and 12 aortic (AVR) valve replacement. Major purpose of the study was to detect the sensitivity of TEE in detecting prosthetic valve malfunction particularly in comparison to TTE. Pannus was detected in 3 and 8 cases of MVR (p < 0.01) by TTE and TEE respectively; however, TEE was found to be of equal status in detecting pannus over AV (2 cases). Physiological regurgitation in MVR and AVR was detected in 13% and 25% by TTE and 20% and 33% by TEE respectively. Paravalvular leak was detected in 3 cases of MVR by TEE compared to only case by TTE. Though it is difficult to deduce any specific conclusion from this small number of patients, there is definite trend to higher sensitivity in detecting disorders with TEE specially for mitral prostheses.

Low-dose amiodarone in severe chronic heart failure.

Sudden cardiac death is a common cause of mortality in patients with congestive heart failure. Asymptomatic ventricular arrhythmia has been attributed as the cause for increased overall mortality in such patients. We conducted a prospective randomised single-blind placebo-controlled trial with low-dose amiodarone to assess its efficacy in reducing mortality in severe congestive heart failure and its effect on exercise tolerance, left ventricular systolic function and ventricular ectopic activity. Patients were randomised to receive amiodarone (n = 36) 400 mg/day orally for one month followed by a maintenance dose of 200 mg/day, or to a standard treatment (n = 40) according to intention-to-treat principle. There were 10 cardiac deaths in the amiodarone-treated group and 16 in the control group. Significant improvement was noted in exercise time in the treadmill test (modified Bruce Protocol) among patients in the amiodarone-treated group while no such statistical difference was detectable in the placebo group. Side-effects in the amiodarone group included asymptomatic rise in hepatic enzymes (three-fold) in 6 percent and proarrhythmia in 3 percent of patients. Nausea was reported in one patient and rash in one. Though low-dose amiodarone proved to be an effective antiarrhythmic agent, it failed to live up to the expectation of improving sudden cardiac death in patients with severe chronic heart failure and asymptomatic ventricular ectopy.

Eye changes in non-specific aorto-arteritis.

Non-specific aorto-arteritis or Takayasu's arteritis is fairly common and has been reported from all parts of India. The disease presents with various eye symptoms such as transient or permanent blindness, headache and signs including neovascularisation, retinal anastomosis, rubeosis iridis, cataracts. Eye manifestations depend on stage of disease and degree of involvement of cervical arteries. This review consists of an indepth impression of eye involvement in non-specific aorto-arteritis.

Risk factors and angiographic profile of coronary artery disease in young.

A total of 124 patients of ischaemic heart disease under 40 years of age (96 with myocardial infarction and 28 with angina) were studied for risk factors of coronary artery disease. Electrocardiogram, treadmill test, lipid profile and coronary arteriography were done in all cases. Smoking (56.4%) and hyperlipidaemia (30.6%) emerged as the major risk factors. Further stratification of lipid profile revealed that predictive value of hypercholesterolaemia could be enhanced by considering the different ratios of lipoproteins and indices of atherogenicity. Coronary arteriography revealed a preponderance of single vessel disease (48.4%)-left anterior descending being most commonly involved (71.8%). Increase in low density lipoprotein fraction was related to multivessel involvement.

Long term follow-up of percutaneous transluminal renal angioplasty with special reference to aorto-arteritis.

Percutaneous transluminal renal angioplasty (PTRA) was attempted in 96 patients of renovascular hypertension (RVHT) admitted during the period 1986 to 1992. The patients' age ranged from 14-70 (mean: 38.7 +/- 18.8) years. There were 42 (43.8%) males and 54 (56.2%) females. The cause of renal artery stenosis (RAS) was aorto-arteritis in 44 (45.8%), atherosclerosis in 28 (29.2%) and fibromuscular dysplasia in 24 (25%). Bilateral RAS was found in 16 (16.7%). PTRA was angiographically successful in 92 (95.8%) patients. The mean pressure gradient decreased from 82.6 +/- 8.2 to 11.2 +/- 3.6 mm Hg in aorto-arteritis, 75.2 +/- 13.2 to 9.6 +/- 6.4 mm Hg in atherosclerosis and from 86.4 +/- 10.6 to 13.2 +/- 8.2 mm Hg in fibromuscular dysplasia respectively. The patients were followed up for 43.2 +/- 24.1 (range: 6-77) months. Remission or satisfactory lowering of blood pressure was achieved in 80 (86.9%) patients. Clinical success rate (remission or satisfactory lowering of BP) at the end of follow-up period was 75.3 percent. Randomly selected repeat angiography was done in 45 out of 92 (49.1%) patients at the end of 24 months of follow-up. Restenosis was detected in 12 (26.7%) patients and was commonest in the atherosclerotic group (42.8%), followed by fibromuscular dysplasia (14.3%) and least common in aorto-arteritis (11.8%). Repeat angioplasty was done successfully in 10 (83.3%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of coronary artery disease by dipyridamole echocardiography test.

Role of oral dipyridamole echocardiography test (DET) was evaluated in 50 patients with effort angina. All patients underwent coronary angiography, the day after oral DET. The echo studies were performed at rest and 65 +/- 15 minutes after 300 mg of oral dipyridamole. Segmental wall motion was analysed in a 16 segment model and a wall motion score index (WMSI) was generated for the entire left ventricle both at rest and following the drug. WMSI was significantly higher after oral dipyridamole, (p < 0.001) compared to resting condition with increased sensitivity (86% vs 74%). When results of DET were compared with coronary angiography, the correlation of WMSI was statistically significant in three vessel disease (p < 0.001), two vessel disease (p < 0.001) as well as for left anterior descending lesions (p < 0.001). However, it was insignificant for single vessel disease, viz, right coronary artery and circumflex artery. Thus we conclude that oral DET is a safe, inexpensive, sensitive and non-exercise dependent method for demonstrating myocardial ischaemia with high diagnostic accuracy.

Effect of intravenous streptokinase on left ventricular function following acute myocardial infarction--an echocardiographic study.

160 patients with first attack of acute myocardial infarction (AMI), admitted within 6 hours after onset of chest pain, were divided into two groups--80 receiving intravenous streptokinase (IVSK, Gr. I) an 80 being treated without IVSK (GR. II). They were studied for pre-discharge (12.5 +/- 2.5 days-post admission) echocardiographic LV function. Gr. I pts received 1.5 million units of IVSK within 6 hrs of onset of chest pain, alongwith beta-blockers, aspirin and heparin unless contraindicated. Gr. II received all these except IVSK alongwith conventional therapy. Highly significant (P < 0.001) improvement was noted in the end-diastolic volume (EDV), end-systolic volume (ESV), Ejection fraction (EF) and regional wall motion score (RWMS) in the anterior wall (AW) AMI group when treated early with IVSK. In the inferior wall (IW) AMI group significant decrease was observed in the EDV and ESV (P < 0.001) and RWMS (P < 0.05), but the difference was not statistically significant for EF. Early high-dose short term IVSK infusion is thus associated with highly significant improvement in LV functions--regional as well as global--especially in AW AMI; in IWAMI the improvement is less marked.

Left main coronary artery compression by dilated main pulmonary artery in atrial septal defect.

Left main coronary artery compression by dilated pulmonary artery in patients with atrial septal defect has previously been reported, but not well characterized. Accordingly, we review retrospectively data of patients with atrial septal defect in whom selective coronary angiograms were done. 41 patients (26 females), aged 47.3 +/- 7.4 years were studied. The pulmonary artery mean pressure was 22.7 +/- 8.3 mm Hg and all patients had left to right shunt ratio of 2:1 or more (mean ratio: 3.9 +/- 1.7). Two patients (4.8%) had left coronary ostial stenosis. There were no clinical or haemodynamic parameters to differentiate the patients with or without these changes. Two patients (4.8%) had coexistent atherosclerotic coronary artery disease. In conclusion, left main coronary trunk compression rarely occurs in patients with atrial septal defect. This information may be relevant in evaluating patients with atrial septal defect.

Enteromesenteric bridge in the treatment o primary lymphedema--a case report.

Technical details and associated problems of enteromesenteric bridging operation for primary lymphedema (proximal obstructive hypoplasia) are discussed. The short term results are encouraging.

Intravenous thrombolytic therapy in unstable angina.

One hundred consecutive age and sex-matched patients of 3 different subsets of unstable angina (recent onset angina -65, crescendo angina -20, post-infarct angina-15) were randomized 1:1 after coronary angiography to receive I.V., either 1.5 x 10(6) units of streptokinase (SK) in 200 ml of normal saline or 200 ml of normal saline alone (control) in 1 hour. Repeat angiography was done in those patients having intra-coronary thrombi (37.3%) during the initial angiography. Both groups received optimal doses of heparin followed by warfarin, aspirin and other standard drugs and were followed up for 6 months. Anginal pain subsided significantly in the SK group-41 (82%) vs 25 (50%) (P < 0.005), especially in patients with recent onset angina (92.5% vs 60%, P < 0.005). Incidence of acute myocardial infarction (AMI) was much less in the SKgp (4(8%) vs 17 (34%) (p < 0.05). Four cases of fatal MI and four cases of sudden cardiac death (SCD) occurred in the control group against none in the SKgp. Requirements of mechanical revascularization was significantly less (P < 0.05) in the SK gp. Angiographic evidence of partial or complete clot lysis was noted in 90% of SK gp. vs 4.8% of control (P < 0.01). Echocardiographically assessed LV function improved significantly with SK-therapy in recent onset (P < 0.05) and crescendo angina (P < 0.001) subsets--however, the improvements in post infarct angina subset were not statistically significant. The beneficial outcome with SK therapy was observed in patients irrespective of angiographic evidence of thrombi.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemodynamic advantage with single chamber rate responsive pacemakers over dual chamber pacemakers during exercise in chronotropic incompetence.

Sequential cardiac chamber activation and chronotropic response are amongst the important determinants of cardiac performance. This study compared VVIR mode with DDD and VVI mode to assess the contribution of these two factors in the determination of cardiac performance during exercise. Ten patients with a mean age of 68 +/- 5 years were studied during 1988-90, who had complete heart block and sinus node dysfunction with a mean LV ejection fraction of 51.5 +/- 6.25%. Five patients had DDD pacemakers and the rest had VVIR pacemakers. Patients were exercised first in VVI mode followed by either DDD or VVIR mode. Exercise duration, maximum rate pressure product, exercise capacity and cardiac output were measured with graded treadmill test in Bruce protocol. There was remarkable increase in the exercise duration (P < 0.001) and the maximum rate pressure product (P < 0.001) in patients with VVIR as compared to DDD and VVI mode. In DDD mode, as compared to VVI mode, this increase was less remarkable, though statistically significant (P < 0.005). Therefore, it is concluded that patients with chronotropic incompetence as well as complete heart block do better during dynamic exercise when they have VVIR mode compared to VVI or DDD mode.

Low dose amiodarone in refractory tachyarrhythmias.

Fifty patients with drug resistant tachyarrhythmias were treated with amiodarone for 6-22 months; 16 for recurrent ventricular tachycardia (VT), 2 for VT followed by ventricular fibrillation (VF), 14 for complex ventricular ectopics, and 18 for supraventricular tachyarrhythmias (SVT). Amiodarone was administered in a dose much lower than that used in western trials. The actual incidence of successful amiodarone therapy was 81.2% at 22 months for patients with VT. Among the patients with SVT, 88.6% patients were successfully treated for 22 months (range 3-22 months). Amiodarone toxicity appeared in 22 of 50 patients (44%) treated for more than 12 weeks. Withdrawal of therapy was required in 4 patients. Despite the lower dose, clinical efficacy and onset of action were comparable to the western experience.