Primary pyomyositis in North India: a clinical, microbiological, and outcome study

BACKGROUND/AIMS: Pyomyositis is an infective condition with primary involvement of the skeletal muscles. There is sparse recent literature on patients with pyomyositis. METHODS: This study was carried out at emergency services of a tertiary care center located in subtropical area of Indian subcontinent. RESULTS: Sixty-two patients of primary pyomyositis formed the study cohort. Mean age of occurrence was 29.9 ± 14.8 years. There were 54 men. Twelve patients had underlying medical diseases. Muscle pain was seen in all 62 patients. Forty-eight patients (77.4%) had the fever. Most common site of involvement was thigh muscles (n = 29, 46.8%). Forty-nine patients (79%) presented in the suppurative stage of illness. Patients with comorbidities were older (age: median 36 years [interquartile range (IQR), 25 to 47] vs. 24 years [IQR, 16 to 35], p = 0.024), had higher culture positivity with gram-negative organisms (8/9 [88.89%] vs. 6/29 [20.69%], p = 0.001). Importantly, higher number of these patients received inappropriate antibiotics initially. Patients with positive pus culture result had higher complication rate (32/38 [84.21%] vs. 10/18 [55.56%], p = 0.044). Six patients (9.7%) had in-hospital mortality. Lower first-day serum albumin, initial inappropriate antibiotic therapy, and advanced form of the disease at presentation were associated with increased in-hospital mortality. CONCLUSIONS: Primary pyomyositis is not an uncommon disease entity. Patients with comorbidities were more likely to receive initial inappropriate antibiotic therapy. Patients with positive pus culture report had the higher rate of complications. Lower first-day serum albumin, initial inappropriate antibiotic therapy and advanced form of the disease at presentation were associated with increased in-hospital mortality.

Treatment failure with disease-modifying antirheumatic drugs in rheumatoid arthritis patients

<p><b>INTRODUCTION</b>Rheumatoid arthritis (RA) patients taking disease-modifying antirheumatic drugs (DMARDs) may experience treatment failure due to adverse effects or a lack of efficacy/resistance. The purpose of this study was to evaluate the prescription patterns, the incidence and reasons for failure, and the time to treatment failure of DMARDs in RA patients.</p><p><b>METHODS</b>The medical records of patients visiting the Rheumatology Clinic were scrutinised retrospectively in order to extract the relevant data, including demographics, clinical and laboratory investigations and drug usage, for analysis.</p><p><b>RESULTS</b>More than 60% of the 474 eligible patients were started on a combination of DMARDs. Hydroxychloroquine (HCQ) (79.7%) and methotrexate (MTX) (55.6%) were the most common DMARDs prescribed initially. There was a significant difference in survival times among the various treatment groups (p ≤ 0.001). Adverse effect was the main reason for treatment failure of sulfasalazine (SSZ) (88.9%) and MTX (75%), while addition or substitution DMARDs was more common for those taking HCQ (72.2%). Adverse event was reported as the most significant predictor of treatment failure. The most commonly reported adverse effects were bone marrow suppression and hepatotoxicity.</p><p><b>CONCLUSION</b>A combination of DMARDs was used to initiate therapy in more than 60% of RA patients, with HCQ and MTX being prescribed most frequently. Adverse effects accounted mainly for treatment failures with MTX and SSZ, while lack of efficacy was responsible for major treatment failures with HCQ.</p>

Severe hypoglycemia following acute aluminum phosphide [rice tablet] poisoning; a case report and review of the literature

Aluminum phosphide [AlP] as 3 g tablet is widely used in Iran to protect stored food grains from pests. Hyperglycemia following its ingestion has been already reported in the recent years but severe hypoglycemia is uncommon. Here, we report a 19 year old male who attempted suicide with one tablet of AlP and demonstrated severe hypoglycemia. Despite restoration of blood glucose concentration to normal, he failed to respond to supportive treatment and died. The possible mechanisms leading to severe hypoglycemia are discussed. Though severe hypoglycemia is rare following AlP poisoning, physicians managing such patients should be aware of it.

Role of neostigmine and polyvalent antivenom in Indian common krait [Bungarus caeruleus] bite

Bungarus caeruleus [Indian common krait] bite during monsoons is common in Northwest India. This study was undertaken to find the effectiveness of neostigmine and polyvalent antivenom in improving neuromuscular paralysis following bite. All the consecutive patients admitted between June 2007 and December 2008 with common krait bite, identified either from brought snake or circumstantial evidence were studied. Ten vials of polyvalent antivenom and three doses of 2.5 mg neostigmine at 30 min intervals after administration of 0.6 mg of atropine were administered I.V. and patients were assessed for any improvement in neuroparalysis. Seventy-two patients were admitted during the study period. All the patients except two came from rural areas and were brought between June and September. Sixty-two patients were bitten during the day while clearing bricks, cutting grass or walking. The mean time interval between bite and arrival to hospital was 4.5 h. None of the patients showed any improvement following treatment and all patients developed respiratory paralysis, requiring assisted ventilation. Seventy survived and two died. Neostigmine is ineffective in reversing or improving neuroparalytic features in patients with B. caeruleus bite even at higher dose than normally recommended