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.

Successful management of hypokalaemia related conduction disturbances in acute aluminium phosphide poisoning.

A case of acute aluminium phosphide poisoning is described, who presented in shock secondary to electrolyte related cardiac rhythm disturbance and the judicious correction of the same could save his life without any consequence.

Meningoencephalitis in brucellosis.

Human brucellosis, more specifically neurobrucellosis, is a less commonly reported disease in India; although, animal brucellosis and seroprevalence in specific areas is well reported. We are reporting 4 cases of neurobrucellosis presenting as meningoencephalitis. Diagnosis was confirmed by serological test and agglutination titre was > 1:320 in all the patients. All these patients had close contact with animals and history of raw milk ingestion was present in 3 cases. The aim of presenting these cases is to create awareness among physicians while treating meningitis in persons, engaged in occupations related to brucellosis or having a history of ingestion of raw milk or milk product.

Poor diagnostic accuracy and applicability of Siriraj stroke score, Allen score and their combination in differentiating acute haemorrhagic and thrombotic stroke.

OBJECTIVE: To evaluate the relevance of bed side clinical diagnostic scoring systems--Siriraj stroke score (SSS), Allen score and their combined use for differentiating acute haemorrhagic and thrombotic stroke. MATERIAL AND METHODS: The study was conducted on 240 admitted patients of stroke over a period of two years. SSS was calculated immediately and Allen score, 24 hours after admission. CT scan was done immediately and 48 hours after admission if required. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain were calculated for both the scores. Comparability between the scores and CT scan finding was determined with the help of kappa statistic programme. Receiver operating characteristic curves (ROC) were plotted to assess the diagnostic accuracy of both scores over a range of cut-off points. RESULTS: One hundred and thirty four patients (55.83%) had infarction and 106 patients (44.17%) had haemorrhage. SSS was applicable in 66.25% patients (159 out of 240) while Allen score was applicable in only 61.25% patients (147 our of 240). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain for SSS were 73%, 85%, 85%, 71% and 30% for infarction and 85%, 73%, 71%, 85% and 27% for haemorrhage respectively, whereas the corresponding figures for Allen score were 91%, 60%, 77%, 82% and 18% for infarction and 60%, 91%, 82%, 77% and 41% for haemorrhage respectively. There was overall moderate comparability between SSS and Allen score for diagnosing supratentorial stroke (k = 0.396). The comparability of these scores in terms of certain results was worse (k = 0.143). However when the results that were within the diagnostic range with both the scores were considered, the agreement in diagnosing infarction and haemorrhage was almost perfect (k = 0.874). While considering CT scan finding as gold standard for differentiation of infarction and haemorrhage, the overall accuracy of SSS and Allen score was seventy eight percent. CONCLUSION: (a) Applicability of SSS only in 66.25% patients and wrong diagnosis in 22.01% patients does not reflect its usefulness because adequate management of stroke requires a gold standard diagnosis which is only possible by immediate CT scan. (b) Allen score is not useful because it can be assessed only after 24 hours of onset of stroke. This deprives the management to all thrombotic patients in speculated time window of modern management.

Clinical profile of neurobrucellosis--a report on 12 cases from Bikaner (north-west India).

OBJECTIVE: To study the spectrum of neurobrucellosis in a prospective study at Bikaner which is supposed to be uncommon in India. METHOD: This study was done on admitted patients of brucellosis from June 1996 to June 1999 in whom the diagnosis was done by history of exposure to animals, fever and arthralgia and demonstration of brucella antibody titres in serum 1:160. CSF examination was done in all the patients. All cases were treated by combination of doxycycline 100 mg twice daily, rifampicin 900 mg daily for 6-8 weeks and injection streptomycin 0.75 to 1 gm i.m. per day for initial 14 days. Detailed neurological examination and antibody titres of serum and CSF again measured at the end of treatment. RESULTS: Twelve out of 92 patients revealed evidence of neurobrucellosis in which four cases were of meningoencephalitis, two cases of myelitis leading to spastic paraparesis, five cases of polyradiculoneuropathy and one case of polyneuroradiculomyeloencephalopathy. The treatment regimen used was associated with a high cure rate and significant reduction in antibody titres in serum and CSF. CONCLUSION: Neurobrucellosis is an uncommon but serious manifestation affecting central and peripheral nervous system. The clinical profile of the disease mimicks closely to commonly seen neurological infective diseases like tubercular meningitis, viral encephalitis, aseptic meningitis, cerebral malaria and viral encephalopathy. Serum and CSF testing for brucella antibody titre is an important test for the diagnosis. Blood culture is not an ideal test for neurobrucellosis because of low yield and longer time required for the diagnosis. High degree of suspicion is prudent for the diagnosis. High degree of cure rate can be achieved by treatment with present regimen in a disease which is otherwise having high mortality and morbidity.