Histoid Leprosy: Are We Still Harbouring Potential Community Menace? A Case Series from North-East India

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. Histoid leprosy is considered an uncommon multibacillary form of leprosy characterized by presence of histoid lepromas which present as erythematous round or oval shaped glistening nodules. Most commonly this form of leprosy is seen in patients on irregular therapy with MDT. In this series we report a total of three cases with their clinical, histopathological and dermoscopic findings.

Evaluation of immunocytochemistry on destained giemsa stained smears as an alternative to conventional technique

Introduction: Protocol for immunocytochemical (ICC) staining in May-Grünwald Giemsa (MGG)–stained smears has been difficult to establish. It is the need of the hour to be able to use prestained slides for ICC in specific cases to deliver timely diagnoses and reduce inconvenience to patients. Aims and Objectives: To evaluate and compare the use of MGG-stained smears for the purpose of ICC, after de-staining and saline rehydration to that of routine standard ICC. Materials and Methods: A prospective study was conducted on 40 FNAC samples: 25 cases of breast disease and 15 cases of reactive lymphoid hyperplasia known to express pancytokeratin and leukocyte common antigen (LCA)/CD45, respectively. Air-dried smears of each case were stained by standard MGG stain and after the report was dispatched, one smear was selected and sent for ICC. The smears were analyzed to determine the overall result and grade each smear semi-quantitatively with respect to staining-intensity, stain-localization, staining-uniformity, counter-staining, and background-staining. Observations and Results: The proposed protocol was inferior to conventional ICC in all the parameters, more pronounced in pancytokeratin than LCA/CD45. Only 8% of air-dried smears stained for pancytokeratin showed optimal stain intensity (as opposed to 44% of wet-fixed smears), whereas only 14.3% of air-dried smears were optimally stained for LCA (as opposed to 85.7% of wet-fixed smears). Conclusion: The proposed protocol of de-stained Giemsa smears as an alternative to conventional technique for ICC was unsuccessful in giving satisfactory results.

Use of CDR-sob and ADAS-cog score to check protective role of Non-steroidal AntiInflammatory Drugs in Alzheimer Disease: A Systematic Review and Meta-Analysis

Background Alzheimer’s disease is the major neurodegenerative disease, affecting more than two third cases of dementia in the world. NSAIDs are widely used anti-inflammatory analgesic agents representing 7.7% of worldwide prescription of which 90% are in patients over 65 year old. Based on mixed findings by different RCTs, a systematic review and meta-analysis on CDR-sob and ADAS-cog score was conducted to develop the better understanding on the protective role of Non-steroidal anti inflammatory drugs (NSAIDs) in AD. Methods Data base search was Pubmed, WebScience and Embase. RCTs investigating the effect of NSAIDs on AD or test scores assessing cognitive function in people without AD at baseline were included. Two indicators ADAS-cog score, and CDR-sob are used. Total 09 studies are included in the present Metaanalysis. Results For ADAS-score pooled the pooled summary effect size was calculated using random effect model was -0.03 with 95% C.I -0.13 to 0.07, which was statistically insignificant (p-value =0.44). For CDRsob score difference, the pooled the pooled summary effect size was calculated using random effect model was -0.09 with 95% C.I -0.29 to 0.11 which was statistically insignificant (p=0.3812).For CDR-sob score, the pooled summary effect size was calculated using random effect model was 0.21 with 95% C.I -0.09 to 0.51, which was statistically insignificant (p-value = 0.1741). Conclusion Present Meta analysis shows that NSAIDs in general are not effective in treatment of AD. They also have no protective effect against development of AD on their sustained use.

COVID-19 Antibodies as Predictor of Severe Dengue among Hospitalized Children with Dengue Illness in the Post-third-wave Period of COVID-19 Infection in India

Background: There were widespread unconfirmed reports about the increased severity of dengue post-second wave of the COVID-19 pandemic in India. It is known that a second dengue infection with a different strain in an individual can trigger antibody-dependent enhancement (ADE). A similar phenomenon is hypothesized for severe COVID-19 infection since both dengue and COVID-19 are viral diseases with different and varying strains. However, much research is needed to confirm this hypothesis. In this context, we intended to assess the severity of dengue illness in relation to previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, possibly the role of COVID-19 antibodies as an early predictor of severe dengue illness. Objective: To assess the utility of COVID-19 antibodies for early identification of severe dengue illness among children in the post-third-wave period of COVID-19 infection in India. Materials and methods: All hospitalized children with dengue illness were categorized as severe (shock and/or hemorrhage and/or multi-organ dysfunction) and non-severe dengue illness (dengue with or without warning signs) as per WHO definition. COVID-19 antibody titers were estimated in both groups. Clinical features and seroprevalence of COVID-19 antibodies were compared in both groups. Result: A total of 31 children were studied (13 severe and 18 non-severe dengue illnesses). The most common symptoms prior to presenting to the hospital included fever (100% in both groups), vomiting (85% in severe and 63% in non-severe), abdominal pain (85% in severe and 50% in non-severe), poor feeding (54% in severe and 28% in non-severe), and skin rashes (15% in severe and none in non-severe). The mean duration from the onset of fever to the first hospital visit was 4.6 days in severe illness and 5.3 days in non-severe dengue illness. The mean duration of hospitalization was 9.7 days in severe dengue illness and 4.1 days in non-severe dengue illness. While 92.3% of all severe dengue had significantly higher COVID-19 antibody titers, it was found elevated only in 44.4% of the children with non-severe dengue illness (p-value 0.0059; Yates’ corrected p-value 0.0179). Conclusion: Clinical symptoms prior to presenting to the hospital were fever, vomiting, abdominal pain, poor oral feeding, and skin rashes. While fever, vomiting, and abdominal pain were seen commonly in both severe and non-severe dengue illnesses, the presence of skin rash during febrile phase is associated with severe dengue illness only. Hospitalized children having severe dengue had increased seroprevalence of COVID-19 antibodies (92.3%) compared to children with non-severe dengue (44.4%). However, there is no corelation of the severity of dengue illness with absolute values of COVID-19 antibody levels. Therefore, the presence of COVID-19 antibodies (previous COVID-19 infection) can be a predictor of severe illness in children with dengue especially if associated with poor oral feeding and skin rashes. The limitation of the study is its lesser sample size to conclude any definitive statement; nevertheless, the study paves way for a similar cohort of a larger sample size to draw conclusions.

Assessment of Factors Responsible for Dropout to Multi Drug Therapy for Leprosy

This study was conducted over 2 years period at two leprosy centers of a Tertiary Care Service Hospitals one located in Eastern Uttar Pradesh and second in northern India to assess the factors resulting in pre-mature termination of anti-leprosy treatment in patients. A total of 124 patients, undergoing treatment for leprosy who consumed MDT for at least a month, then stopped it and thereafter reported to us for various reasons, were included. It was observed that 41.1% (51/124) patients dropped out on MDT. 33% (41/124) of the patients who stopped the medication were not formally educated. Most common disease forms observed in these patients was Borderline Lepromatous (BL) and Lepromatous Leprosy in 41.1% (51/124). 49.1% (61/124) patients completed 2-5 months of therapy with MDT prior to stopping it and 38.7% (48/124) patients reported back to us within 2-5 months after suspension of MDT. Reason for reporting in 31.4% (39/124) of these patients was development of deformities while 25% (31/124) reported due to weakness of hands and feet. 23.3% (29/124) developed lepra reaction becoming the reason for their reporting to us for review. Social stigma was the most common factor leading to termination of drug therapy against advice in 25.8% (32/124) patients, 21.7% (27/124) cited loss of occupational hours while 11.2% (14/124) patients felt there was no need to take MDT. To conclude non-compliance to multi drug therapy for leprosy is one of the major obstacles in achieving a leprosy free world and we need to look into all the personal, health care related and social factors responsible for it. Although these factors may vary depending upon the region, society, efficiency of the health care system and the individual commitment level of the patients, the need for better communication at professional and user level is apparent. Focus should be on psychological counselling, motivation of patients, their families and a receptive society to reduce the source of infection, complications and deformities which are otherwise largely preventable and adherence to treat will also prevent of emergence of resistance to MDT. Modified strategy(ies) addressing the factors as identified in this study well in time can make a difference.

Unilateral acute hydrops in a child with bilateral microcornea and iridofundal coloboma

A 15-year-old female child with history of bilateral poor vision since childhood presented with sudden onset pain, photophobia, and diminution of vision OD for 10 days. Visual acuity was hand motion OD and 1/60 OS. Slit lamp examination revealed microcornea OU with multiple intrastromal fluid clefts OD and an irregular cornea and iridofundal coloboma OS. A clinical diagnosis of acute corneal hydrops OD was made, and the child was subjected to intraoperative optical coherence tomography guided intrastromal fluid drainage with air tamponade. The corneal edema resolved completely within 2 weeks resuming visual acuity to 3/60 allowing laser delimitation of fundal coloboma OD.

Posterior laser barrage in advancing retinopathy of prematurity: A prospective randomized study

Purpose: To compare the outcomes of conventional laser photocoagulation versus additional posterior barrage laser in advanced stage 3 retinopathy of prematurity (ROP). Methods: A total of 20 infants with bilateral symmetric zone 2 stage 3 advancing ROP were treated with conventional laser treatment followed by randomization of one eye to receive additional posterior retinal laser treatment. Disc–fovea and inter-arcade distance was measured. The patients were followed up prospectively for 3 months. Structural and functional outcomes and safety profile were analyzed. Results: 18/20 (90%) eyes in the study group and 19/20 (95%) eyes in the control group achieved regression of disease. Faster and complete regression was observed at 4 weeks after posterior laser compared to the control group (P = 0.024). Disc–fovea and inter-arcade distance was comparable in both groups. Conclusion: Additional posterior barrage laser is a safe technique that led to faster and more complete regression in eyes with advancing ROP. Final regression profile was comparable in both treatment modalities.

Tumor budding in infiltrating breast carcinoma: Correlation with known clinicopathological parameters and hormone receptor status

Introduction: Tumor budding (TB) is proposed as an essential step in the invasion and metastasis of various tumors. However, there is limited information about its role in breast cancer. This study was designed to assess the prognostic significance of TB in clinical practice. Objectives: To study and grade TB in patients with invasive breast cancer and to correlate it with known prognostic parameters. Materials and Methods: In this prospective study, 40 cases of invasive breast cancer were studied over a period of 1.5 years. Tumor buds were defined as comprising five tumor cells or less at the invasive front of the tumor. Cases were separated into two groups according to TB density as low grade and high grade. Significance and correlation between TB with established clinicopathological parameters and hormone receptor status were studied by Chi-square test. P value <0.05 was considered significant. Results: All 40 cases in this study were newly diagnosed cases, who did not receive any therapy. The majority of patients were premenopausal (55%), had small tumor size ?5 cm (67.5%), had negative lymph nodes (67.5%), had grades 2 and 3 (75%), and presented in stages 1 and 2 pathological stage (62.5%). The majority were estrogen-receptor-negative (62.5%), progesterone-receptor-negative (65%), and human epidermal growth factor receptor-2-positive (52.5%). Higher grade TB was observed in larger tumor (P = 0.03), in higher stage (P = 0.046), and in tumor having lymphovascular emboli (P = 0.03) when compared with small size, lower stage, and tumor with no lymphovascular emboli, respectively. Conclusion: As higher grade TB was associated with larger, higher stage tumor, and in tumor having lymphovascular emboli, it can be recognized as an easily identifiable prognostic factor.

Direct immunofluorescence findings in cicatricial alopecia: A retrospective study of 155 cases

Objectives: To study the direct immunofluorescence (DIF) in cicatricial alopecia (CA) patients. Materials and Methods: Approximately, 155 skin biopsies from CA patients examined over 7 years (2009–2015). Special stains and Hematoxylin and Eosin were performed, and final histopathological diagnosis was made. DIF (against anti-IgG, IgM, C3, IgA, and fibrinogen) on all these cases and patterns were noted. The descriptive statistics were applied along with ANOVA test. Results: Approximately, 155 patients with Male: Female = 1.24:1, age 7–65 years. In total, 57 cases were of Lichen planopilaris (LPP; 36.7%), 22 Lichen planus (LP; 14.2%), 22 Psuedopalade of Brocq (PPB; 14.2%),16 discoid lupus erythematosus (DLE; 10.3%), 8 end-stage scarring alopecia (ESSA; 5.2%), 2 cases each of Fungal folliculitis (FF), and Folliculitis decalvans (FD; 1.3% each), and in 26 cases, no specific diagnosis could be reached were collectively kept in the category of non-specific findings (NSP; 16.7%). On DIF: LPP positive for IgG = 4 cases (7%), IgM = 26 (45%), IgA = 11 (19.3%), C3 = 16 (28.1%), and fibrinogen = 11 (19.3%). LP positive for IgG = 2 (9%), IgM = 18 (81%), IgA = 2 (9.1%), C3 = 10 (45%), and fibrinogen = 1 (4.5%). DLE positive for IgG = 6 (37%), IgM = 8 (50%), IgA = 1 (6.3%), C3 = 9 (56%), and fibrinogen = 1 (4.5%). Limitations: Because this was a retrospective study, clinical follow-up and treatment history of the patient could not be retrieved. Conclusions: IgG positivity helps significantly in differentiating LPP from DLE (P 0.004) and NSP from DLE (P 0.005). IgM positivity helps significantly in differentiating LPP from LP (P 0.04), LP from PPB (P 0.00) and NSP (P 0.00). C3 positivity helps significantly in differentiating PPB from DLE (P 0.02).

Interesting and Unusual Presentation(s) of Leprosy Resulting in Delayed diagnosis

In the post elimination phase of leprosy programme, it continues to be an important health problem in India. Further various atypical forms are seen resulting in delayed diagnosis. A retrospective analysis of 2 years (January 2016 to December 2017) records of all in and out patients of leprosy cases who were treated at a service hospital in northern India was done. At this hospital a total of 97 leprosy cases were seen during the study period out of which 18 (18.5%) cases where the diagnosis was missed due to various reasons resulting in delay in initiation of MDT were included. These cases were examined to describe the clinical presentation, delay in diagnosis and its significant outcome. 61% (11/18) were males while 39% (7/18) females. 22.2% (4/97) had Histoid Hansen's disease; 22.2% (4/18) had chronic symmetrical polyarthritis, there was no hypoaesthetic or anesthetic patches or enlarged nerves in these patients and these were initially diagnosed and managed as Rheumatoid arthritis. 16.6% (3/18) had spontaneous ulceration of extremities and had no skin infiltration or thickened nerve on examination. Interestingly two of these three patients had associated hypoaethesia of extremities which was not taken into consideration for making diagnosis as no suspicion of leprosy was made, one patient in this group had developed foot drop (L) and Right ulnar claw. 16.6% (3/18) had pure neuritic leprosy while greater auricular nerve thickening was seen in 11.1% (2/18) atypical cases. 5.5% (1/18) patient had swelling of upper lip but there no lesion on face or nerve and was managed by a Dentist. Lichenoid lesions were seen in 5.5% (1/18) cases. Out of 18 atypical cases 83.3% (15/18) were in multibacillary pole while 16.6% (3/18) were in paucibacillary pole. 27.7% (5/18) each were BL and LL while 22.2% (4/18) each were Pure neuritic and Histoid Hansen's. 83.3% (15/18) patients were Bacillary positive. Grade 2 deformity developed in 22.2% (4/18) of these cases. The total duration elapsed between presenting to the primary care giver and the dermatology center where the final diagnosis was made ranged from 2 weeks to 3 years. Increase in awareness about various presentations of leprosy in post-elimination era should be emphasized to the health care physicians as well as other workers involved in detection/diagnosis of leprosy

Synovial hemangiomas of wrist and ankle joint: A report of two rare cases

Synovial hemangioma is a rare, benign, vascular tumor of synovium leading to joint pain and swelling. The most common site is the knee joint, but rare cases involving other sites have also been reported. We report two rare cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint. Histopathology is the gold standard for diagnosis of these cases. Early treatment is warranted to prevent the risk of permanent joint damage.

Bipartite Atlas –A Rare Entity, a Study of Its Incidence in North Indians

Background:Combined anterior and posterior C1 bifidityi.e BIPARTITE ATLAS or SPLIT ATLAS is a rare entity Our goal in this study was to examine the incidence of this anomaly in North India. review the literature and the clinical implications of this cleft defects.. Methods:It is retrospective study ofNCCT evaluation in 1735 patients who underwent CECT neck[900 patients] NCCTwith spine evaluation[835patients]in Pankaj diagnostic set up between jan 2012 to December 2016, and department of radiodignosis Sarojini Naidu Medical college Agra during the time interval between dec 2016 to july 2017 the images were reviewed retrospectively to identify patients with BIPARTITE ATLAS defects . Posterior arch defects of the atlas were grouped in accordance with the classification of Currarino et al ,anomalies were subsequently grouped. Results: We found only 4(4/1735) patients of bipartite atlas i.e .2% of total . anterior ach defects were midline and have a reported width ranging from 1-5 mm The type A posterior arch defect was found in 3 patients and the type B posterior arch defect was found in one patients. No type C, D, or E defects were observed in these bipartite atlas defect The CT scans of the patients show midline clefts of the anterior and the posterior arches of C1 with similar imaging features:smooth margins lined by cortical bone and no lateral offset. The patients had no neurological symptoms relating to the C1 abnormality, and no follow-up was performed.Conclusion:Bipartite atlas is a rare entity as it’s incidence was found to be just .2% . knowledge is essential as it can predispose to certain neurological compressive disorders.awareness helps in clinicoradiological diagnosis, management in patient of trauma as appearance of cleft simulate Jefferson fracture.

Human Milk Banking Guidelines.

Justification: WHO and UNICEF state that the use of human milk from other sources should be the first alternative when it is not possible for the mother to breastfeed. Human milk banks should be made available in appropriate situations. The IYCF Chapter is actively concerned about the compelling use of formula feeds in the infants because of the non availability of human breast milk banks. Process: A National Consultative Meet for framing guidelines was summoned by the IYCF Chapter and the Ministry of Health and Family Welfare, Government of India on 30th June, 2013, with representations from various stakeholders. The guidelines were drafted after an extensive literature review and discussions. Though these guidelines are based on the experiences and guidelines from other countries, changes have been made to suit the Indian setup, culture and needs, without compromising scientific evidence. Objectives: To ensure quality of donated breast milk as a safe end product. Recommendations: Human Milk Banking Association should be constituted, and human milk banks should be established across the country. National coordination mechanism should be developed with a secretariat and technical support to follow-up on action in States. Budgetary provisions should be made available for the activities.

Experience with treatment of pulmonary alveolar proteinosis from a tertiary care centre in north India.

Background. Pulmonary alveolar proteinosis (PAP) is a disorder characterised by accumulation of lipids and proteins in the alveoli, with the resultant symptoms ranging from indolent subclinical disease to progressive respiratory failure. Methods. We retrospectively studied five patients with PAP managed at our center between January 2007 and April 2010, with whole lung lavage (WLL) and/or subcutaneous granulocyte macrophage-colony stimulating factor (GM-CSF) therapy. Patients undergoing WLL under general anaesthesia were supplemented with three months of GM-CSF therapy. Pre- and post-lavage symptom assessment was performed with a 10-point, symptom-based visual analogue scale. Results. Their mean age was 37.6±7.0 years; there were four males. Diagnosis of PAP [idiopathic (n=3); secondary to Nocardia (n=1)] was established by surgical lung biopsy in four patients who presented with respiratory failure. Three patients with idiopathic PAP (n=3) were treated with a combination of GM-CSF and WLL; one patient with secondary PAP was treated with antibiotics alone. In another patient transbronchial lung biopsy was used to diagnose PAP and GM-CSF alone was administered. All patients were followed up for a median period of two years (range 0.5-3 years). Significant improvement was achieved in all the patients with therapeutic WLL and/or GM-CSF. Conclusions. Whole lung lavage appeared to be an effective and safe therapy in patients with PAP. Efficacy of simultaneous administration of GM-CSF and WLL in the treatment of PAP merits further study.

Initial experience of endobronchial silicon stents from a tertiary care centre in north India.

Background. Central airway obstruction (CAO) is defined as obstruction of trachea and principal bronchi. Therapeutic rigid bronchoscopy with tracheobronchial stenting using silicon stents is a well established procedure in the management of such conditions. However, there is limited experience with this technique in India. Methods. Between January 2010 and April 2010, Dumon stents were placed in four patients with CAO. Three patients had symptomatic tracheal stenosis while one patient had malignant obstruction at the carina. Rigid bronchoscopy under general anaesthesia was performed to relieve the CAO followed by placement of silicon stents. Pre- and post-stent placement symptom assessment was performed with a symptom-based visual analogue scale. Results. Four patients underwent silicon stent placement in the tracheobronchial tree. Three patients had benign postintubation tracheal stenosis and one had malignant tracheal obstruction at carina due to endobronchial growth. Significant improvement was achieved in all patients. There were no significant complications. Conclusions. Rigid bronchoscopy with silicon stent placement is an effective and suitable method of relieving the distressing symptoms due to benign or malignant airway obstruction.

Immune responses to mycobacterial antigens in sarcoidosis: A systematic review.

From the time sarcoidosis has been described, there has always been a viewpoint that the disease is in some way related to tuberculosis (TB). Sarcoidosis is a granulomatous disease, which is likely a result of continued presentation of a poorly degradable antigen. Mycobacterium tuberculosis has been a very strong contender for this antigen. Besides the molecular studies demonstrating mycobacterial deoxyribonucleic acid (DNA) in the sarcoid tissue, assessment of immune responses against mycobacterial antigens provides a useful tool to study the role of mycobacteria in the pathogenesis of sarcoidosis. We reviewed the studies focussing on T-cell and B-cell responses to tubercular antigens in patients with sarcoidosis. Pooled data from various studies does provide a suggestive, though not unequivocal evidence in favour of mycobacteria as a cause of sarcoidosis. These findings not only reinforce the possible pathogenic role of mycobacterial antigens in sarcoidosis, but at the same time also limit the clinical utility of molecular and serological studies based on mycobacterial antigens in the differential diagnosis of TB from sarcoidosis, particularly in a country with high endemicity for TB.