Expansile lake of translucency in pericardial effusion. A manifestation of left ventricle to pericardial fistula from rupture of tuberculosis myocardial abscess

A 12 year old boy was admitted to a District hospital with history of abdominal pain, and persistent vomiting of several days duration. Exploratory laparotomy was done and terminal small intestine appearances were suggestive of ileocaecal tuberculosis. During post operative course he was found to have large bilateral pleural effusions on chest x-ray. Subsequently his general condition deteriorated and he was then shifted to tertiary care hospital where chest intubation was done. Echocardiography revealed large pericardial effusion with tamponade which was drained with a pigtail catheter, kept in situ for intermittent drainage. Clinical workup and investigations were consistent with disseminated tuberculosis for which anti-tuberculosis treatment was started. A month later, echocardiography was repeated for removal of pigtail catheter which revealed lake of translucency within the small residual pericardial fluid which was expansile with cardiac cycle. This was further evaluated with colour and colour M-mode. [Panel A,B,C,D]. Findings were suggestive of fistulous communication between left ventricular cavity and pericardial space secondary to tuberculous myocardial abscess rupture confirmed on histopathology post-operatively. What lends novelty to this case is that this serious but apparently innocuous looking finding could easily have been overlooked in a casual examination

Prevalence of enteric fever in Karachi

To find out the common strains causing enteric fever in the population and to compare the antimicrobial susceptibility strains isolated from indoor and outdoor patients. A total of 300 clinically suspicious cases of enteric fever were enrolled from the wards and OPDs of Jinnah Postgraduate Medical Center [JPMC], National Institute of Child Health [NICH] and Civil Hospital, Karachi [CHK] during the period of August 2004 to May 2005. Important laboratory investigations carried out included blood culture, slide agglutination test and antimicrobial susceptibility. Out of 300 patients selected 172 proved positive for Salmonella with 87.2% being S.typhi, 21 [12.2%] Para A and 1 [0.6%] Para B. Among the 86% indoor and 14% out door cases positive, 70.3% were from NICH, 15.1% from Civil Hospital, Karachi while 14.5% from JPMC respectively. Catchment area distribution showed 28.7% from East, 28% from South, 16.7% from Central, 14% from Malir, 5.7% from West and the remaining 7% were from outside Karachi. Chloramphenicol sensitivity was 47 [27%], ampicillin 44 [25.6%], trimethoprim sulphamethoxazole 4 [2.32%], cefixime 167 [97%], ceftriaxone 169 [98.8%] and ofloxacin 170 [98.8%]. Typhoid afflicts a large number of people in Karachi. Provision of safe drinking water, hygienic food and efficient sewerage system are therefore mandatory for prevention of typhoid