Prevalence of parenterally transmitted hepatitis viruses in clinically diagnosed cases of hepatitis.

Hepatitis B virus (HBV) is the most important causative agent of blood borne hepatitis in humans. Hepatitis D Virus (HDV) infection occurs either as a coinfection or superinfection in HBV carriers. Hepatitis C virus (HCV) is the major cause of transfusion non-A, non-B hepatitis and continues to be a major cause of human liver disease throughout the world. The present study was conducted on 70 clinically diagnosed cases of viral hepatitis to study the prevalence of parenterally transmitted viral hepatitis. The serum samples were tested for HBsAg, HBeAg, IgM anti-HBc, anti-HBe, anti-HCV and anti-HDV using separate ELISA kits. Of the 70 serum samples tested, 28 (40%) were positive for HBsAg out of which 3 (4.28%) were positive for HBeAg also. Five (7.1%) of the HBsAg positive cases tested positive for IgM anti-HBc also. HBsAg alone was found in 17 (24.28%) cases. The prevalence of anti-HCV was 3 (4.28%) in 70 cases. Thus early screening of clinically diagnosed cases of viral hepatitis is essential for establishing diagnosis and treatment to prevent long term sequelae.

Chronic lymphocytic leukemia manifested by steroid responsive polyneuropathy.

We report a patient of acute demyelinating polyneuropathy who on investigations turned out to be suffering from chronic lymphocytic leukaemia (stage 0). Response to steroid therapy suggests an autoimmune process as a cause of polyneuropathy. Chronic lymphocytic leukaemia manifested by acute polyneuropathy has been described rarely in literature.

Utility of bone marrow aspiration in extrapulmonary tuberculosis.

This study was undertaken to look for evidence of acid fast bacilli (AFB) in bone marrow (BM) in patients of extrapulmonary tuberculosis. Fifty cases suspected of extrapulmonary tuberculosis underwent bone marrow aspiration from sternum/illiac crest and were put on a therapeutic trial of antituberculosis therapy. All cases taken in the study responded to the therapy. The pattern of involvement were – abdominal (20), CNS (19), pericardial involvement (5), cervical lymphadenopathy (2), PUO (2), spinal (1) and miliary (1). 52% cases showed evidence of AFB in BM (on Ziehl Neelsen’s (ZN) staining) whereas only 4% of cases showed evidence of AFB in any other body fluid (CSF/pericardium/peritonium). Besides this, cytomorphological changes of BM showed evidence of lymphocytosis (22%), increased plasma cells (80%) and prominence of macrophages (88%), thus signifying infective pathology with macrophage overactivity. So we conclude that bone marrow aspiration has a definite diagnostic value and may prove useful when other investigations are unrewarding.

A profile of renal/renovascular abnormalities in patients of hypertension.

After a thorough dinical examination and laboratory investigations, ultrasonography (USG) followed by minute sequence urography (MSU) and aortography and/or selective renal angiography were done in 108 patients, clinically suspected of having renal hypertension of which 32 patients (29.6%) were found to be positive for renal/renovascular disease. Out of 82 patients, who were only young hypertensives, a definite diagnosis of renal/renovascular disease could be made in only 15 cases (18.3%), whereas the pick up rate increased to 65.4% in the rest of the 26 patients who had some other clinical criteria besides hypertension and it further increased up to 92.3% (out of these 26 patients) who had 2 or more than 2 clinical criteria of selection of patients besides hypertension. USG was useful in diagnosing renal parenchymal disease/ suggesting renal abnormalities in 30 cases and MSU was able to detect renal changes in 31 patients. Aortography and/or selective renal angiography could make a definite diagnosis of renovascular disease in 17 cases and renal agenesis in one case.

Intracardiac mass lesions: experience of 14 cases.

Mass lesions within the heart are often encountered during routine echocardiography. The nature of such masses can generally be suspected depending upon clinical setting. During 13 years of our experience in echo lab, we came across 14 patients with large intracardiac masses (some of them, rare type). Clinical features, echocardiographic findings and histopathological confirmation which was possible in majority of them, are described. Five of our patients had cardiac tumour (myxoma), four had large intracavitary thrombus, while pieces from two patients were demonstrated to have large vegetations and hydatid cyst(s). One patient, suspected to have vegetation on mitral valve, turned out to have thick myxomatous tissue deposits on histopathology. Two-dimensional echocardiographic features of intracardiac mass lesion are generally dependable in deciding nature of such lesions. However, very large thrombus and vegetation mimicking cardiac tumour are rarely encountered.

Cardiac arrhythmias in aluminium phosphide poisoning studied by on continuous holter and cardioscopic monitoring.

Variable incidences of cardiac arrhythmias (based on isolated 12 lead ECG records) have been reported in patients of aluminium phosphide (ALP) poisoning. We did continuous holter and cardioscopic monitoring in ICU in 30 patients of acute ALP poisoning. Supraventricular and ventricular ectopics were recorded in each and every patient. Life threatening ventricular tachycardia was recorded in 40% cases and ventricular fibrillation in 23.3% cases. Supraventricular tachycardia and atrial flutter/fibrillation occurred in 46.7% and 20% patients, respectively. ST-T changes simulating myocardial ischaemia were also present in all patients (S-T depression in 90%, S-T elevation in 10%). One-third of the patients developed variable degrees of heart block, IV amiodarone/xylocard could revert dangerous ventricular arrhythmias to sinus rhythm in 4 cases. Toxic myocarditis produced by phosphine seems to be responsible for the development of these arrhythmias.

Profile of young acute myocardial infarction in Harayana.

Profile of acute myocardial infarction (AMI) in young patients (below 40 years) was studied in a rural/semi-urban population. Out of the total 338 patients who were admitted to ICCU over a period of one year, 65 (19.2%) were aged 40 years or below (Range 14-40 years). Male:female ratio was 20:1. Majority of these young patients were thinly built, engaged in heavy physical work and belonged to lower socio-economic group. Smoking was the most common risk factor (87%); other risk factors were few. Majority of these young patients ignored chest pain and reported late to the hospital. However, despite this, incidence of complications/mortality was less in comparison to their older counterparts. The overall mortality was only 6% as compared to 21% in older age group. The study focuses our attention to the rising incidence of AMI in young individuals even in populations least prone to ischaemic heart disease. Smoking was the only modifiable risk factor which needs to be curbed with full force.

The changing profile of Plasmodium falciparum malaria.

Resurgence of malaria has been noted in the Rohtak district (Haryana, India) after the recent floods. The profile of 66 patients of P. falciparum infection who were admitted to our hospital over one month in October 1995 is reported. While only a minority of cases (< 15%) presented with an uncomplicated course, all others developed one or more complication(s), some of them very rare. The usual manifestations viz, cerebral malaria, black water fever and algid malaria seen in the past were observed in less than half the patients. The remaining presented with unusual complications like haemolytic anaemia (46.2%), severe anaemia (37.9%), thrombocytopaenia (18.2%), pancytopaenia (6%), adult respiratory distress syndrome (4.5%) often not seen in sporadic cases of falciparum malaria which occurred in the past in this district. Similarly all deaths (15.1%) were noted in patients with rarer manifestations and only one patient died of cerebral malaria. This study confirms the occurrence of severe and complicated falciparum malaria in this part of the country.

The profile of acute poisonings in Harayana-Rohtak Study.

A prospective study of 559 cases of acute poisoning who came to this hospital over a period of 14 months. 91.4% cases were of self poisoning (suicidal), 8.1% accidental and only 0.5% homicidal. Majority of patients were young (mean age 27 years), males twice the number of females. Almost 3/4th of the total patients belonged to lower socio-economic group (rural more than urban). The common causative factors which led to self poisoning were marital disharmony, economic hardships and scolding/disagreement with other family members. Aluminium phosphide (ALP) was the most commonly abused substance followed by organophosphates and zinc phosphide in 67.8, 13.9 and 4.3% cases respectively. The overall mortality rate in the series was 33.82%, but true mortality rate in patients who consumed ALP was as high as 67.6%. Most of these cases (94.9%) were not given any preliminary treatment in the village primary health centre (PHC) nearest to the site of mishap and they were brought/referred to this hospital straight and thus most valuable time crucial for effective treatment was lost. Easy availability of a highly toxic substance like ALP at peak moments of frustration has added fuel to the fire and pushed up the incidence of self-poisoning. Suggested preventive measures include caging of tablets in plastic packs, stringent restrictions on free supply of ALP and education of medical/paramedical personnel involved in health care delivery at grass root level.

Tissue magnesium content and histopathological changes in non-survivors of aluminium phosphide poisoning.

The study was conducted in 30 non-survivors of Aluminium Phosphide poisoning and similar number of age and sex matched controls (fatalities as a result of road side accidents, head injury, etc). Magnesium content was estimated in brain, heart, stomach, kidney, liver and lung using atomic absorption spectrophotometer. It was found that tissue magnesium levels were not significantly different (p = NS) when comparison was carried out between controls (Group II) and Patients who were not given magnesium as part of treatment (group IB). However magnesium levels in different organs of patients who received magnesium as part of treatment were found to be significantly higher (group IA)(P < 0.01) in comparison to controls as well as patient group not treated with magnesium sulphate. Significant histopathological changes were observed in almost all the organs. The changes seem to be the result of direct tissue damage by phosphine rather than shock and anoxia which occurred in all these cases.

Serum & tissue magnesium content in patients of aluminium phosphide poisoning and critical evaluation of high dose magnesium sulphate therapy in reducing mortality.

Role of high dose magnesium sulphate therapy was evaluated in 50 patients of Aluminium Phosphide (AIP) poisoning. Simultaneously serum and RBC magnesium levels were studied in these patients at six different points within first 24 hours. In non-survivors magnesium content of various tissues (brain, stomach, kidneys, liver, lungs and heart) was also estimated. Magnesium estimation (tissue as well as serum) was done using atomic absorption spectrophotometer. No significant difference was found in dose related mortality rates in patients treated with and without magnesium sulphate. The immediate causes of death in these patients included intractable shock, shock coupled with arrhythmias and adult respiratory distress syndrome (ARDS). Serum as well as RBC magnesium content was within normal range at all the six points (0, 1, 3, 6, 12 and 24 hours after arrival in hospital). Tissue magnesium content of various organs (in non-survivors) was more (p < 0.01) compared to that of corresponding organs in controls (accidental deaths). No significant alterations were seen in other serum electrolytes (Na, K, Ca, PO4). The data confirmed that neither there was any evidence of hypomagnesemia in these patients nor magnesium sulphate therapy improved survival. Survival can be improved (to some extent) with continuous cardiac monitoring and use of appropriate anti-arrhythmic agents. However, imposition of stringent restrictions on the free supply of AIP and caging of tablets in plastic packs with holes and spikes may yield better results in preventing AIP poisoning rather than treating these patients.

Comparative evaluation of dopamine infusion & treadmill exercise tests in the diagnosis of coronary artery disease.

Dopamine infusion test (DIT) was compared with treadmill exercise test (TMT) in 20 patients of chronic stable angina (TMT +ve) for inducing reversible myocardial ischaemia so as to assess its efficacy as an alternative to TMT in patients who cannot perform exercise test due to certain non-cardiac diseases. DIT was positive in 15 of the 20 patients studied; five patients in whom DIT was negative had late onset, early offset changes in TMT. Haemodynamically the increase in heart rate (HR) was less but rise in systolic blood pressure (SBP) was more with dopamine infusion in comparison to the corresponding stage of TMT. However, evidence of myocardial ischaemia (ST segment depression) appeared at a lower rate pressure product (RPP) with dopamine infusion compared to exercise test. The test was tolerated well, in higher doses (stages III & IV) side effects like ventricular ectopic beats, palpitation and angina not warranting stoppage of test, were seen in some patients. Dopamine infusion is a good chemical stress test, and can be used as an alternative to TMT especially in situations where the latter cannot be performed. The test is simple, cost effective, non-invasive and well tolerated.

Effect of atenolol and labetalol on serum lipids.

Adverse alterations in lipid profile suggesting higher atherogenicity were observed following 12 weeks treatment with atenolol in patients of hypertension. No significant alterations in lipid profile were observed with labetalol therapy.

Saddle embolism of aorta.

Aortic saddle embolus is a rare but serious form of arterial embolisation in patients with myocardial infarction. Four patients with aortic saddle embolism with peripheral propagation of the clott are reported. Two patients had suffered an attack of acute anterior myocardial infarction (one and four weeks respectively) prior to the embolic episode. One patient had a transmural myocardial infarct five years ago, and the 4th patient had dilated cardiomyopathy. The onset was sudden, marked by pain, parasthesias, pallor, pulselessness in three patients, and gradual in one. Two of the three patients (both females) in whom clott migration occured in only one limb developed below-knee gangrene of the affected side. In one patient (a young male) clott migration occurred in both popliteal arteries and the limbs were spared from developing gangrene although he continues to have leg angina. One patient presented with intermittent calf claudication only. All our patients reported late due to which none could be subjected to embolectomy.

Estimation of 24 hour protein excretion from single random urine specimen.

The product of protein/creatinine ratio (in a random urine specimen) and estimated daily urinary creatinine excretion were evaluated as a function of 24 h urinary protein excretion in 40 patients with pathology proteinuria having varying grades of renal function. An excellent correlation was found between the results obtained by this method and those from the standard 24 h urine collection method in healthy controls (r = 0.99) and in patients with normal (r = 0.88) or mild to moderately impaired renal function (r = 0.99). However, this method did not give a good measure of quantitative proteinuria in patients with advanced renal failure (r = 0.56), possibly due to decreased urinary excretion of creatinine in patients with advanced renal failure as compared to the estimated value. The product of protein/creatinine ratio and estimated daily urinary creatinine excretion thus gave a quick and alternate reliable method of estimating 24 h proteinuria in patients having normal or mild to moderately impaired renal function. However, this method is not suitable for patients with advanced renal failure.

Myositis ossificans in tetanus. A rare complication.

Myositis ossificans developing as a complication of tetanus is very rare. There are only nine cases reported so far. We report here a case of a young female who developed myositis ossificans in both the elbow joints as a complication of severe tetanus.