Kikuchi-fujimoto disease.

A 14 year-old Bangladeshi girl presented with high fever, painful swellings in the neck, anorexia, weight loss and night sweating. On examination she had multiple enlarged and tender cervical lymph nodes. Other systems were normal. Laboratory investigations for sepsis and autoimmune diseases were negative. Initial fine needle aspiration and cytology of affected lymph node was suggestive of tubercular lymphdenitis. But she did not respond to anti-tubercular treatment. Kikuchi-Fujimoto disease was diagnosed from the histopathological appearance of excised lymph node. She completely recovered with symptomatic treatment. Kikuchi-Fujimoto disease, also called Kikuchi's disease or histiocytic necrotizing lymphadenitis is a rare, benign but enigmatic disease of unknown aetiology. The disease is self-limited and has an excellent prognosis. Its recognition is crucial because it can be mistaken for systemic lupus erythematosus, malignant lymphoma, tubercular lymphadenitis or even, for metastatic adenocarcinoma. Clinicians' and pathologists' awareness of this disease may help prevent misdiagnosis and inappropriate treatment.

Urinary iodine status and thyroid dysfunction: a Bangladesh perspective.

Iodine deficiency is endemic in Bangladesh. Compulsory iodization of table salt was introduced since 1993 to prevent and improve thyroid disorders in the country. Urinary iodine status, thyroid function and antithyroid antibodies were studied in 397 newly diagnosed thyroid patients and 94 age-sex matched controls. Among thyroid patients, 96 were hyperthyroid, 185 euthyroid and 116 hypothyroid. Mean and median urinary iodine were higher (p=0.075) in thyroid patients (26.13+/-0.91 and 23.03) than controls (22.65+/-1.47 and 18.59); in hyperthyroid and euthyroid than hypothyroid (p=0.020); in multinodular (28.08+/-2.80 and 26.94) and diffuse (27.35+/-1.19 and 26.71) goitre than uninodular (23.91+/-2.37 and 19.14) and nongoitrous (NG, 21.5+/-2.05 and 18.27) (p=0.098) patients but no sex difference (p=0.466). Antimicrosomal (26.7%) and antithyroglobulin (34%) antibodies were more frequently positive among thyroid patients than controls (6.4% and 12.8% respectively) (p=0.00002 and p=0.00005 respectively). Antibody positivity was higher in diffuse (82/228) and multinodular (20/47) goitre than nongoitrous (20/56) and uninodular (13/66) goitre (p=0.046) as well as in hypothyroid (55.2%) and hyperthyroid (36.5%) than euthyroid (19.5%) patients (P<0.001). Urinary iodine correlated neither with antimicrosomal (thyroid patients: p=0.597 and control: p=0.112) nor with antithyroglobulin (thyroid patients: p=0.388 and control: p=0.195) antibody. Thyroid autoimmunity and dysfunction seems common; and interaction of salt iodization with iodine status and thyroid disorders may be important in Bangladesh.

Predominance of the DEN-3 genotype during the recent dengue outbreak in Bangladesh.

A recent outbreak of dengue in Bangladesh was marked by many fatal complications. As clinical virulence varies among the genotypes of dengue virus, a study was conducted to investigate the molecular genotypes of dengue in Bangladesh. Reverse transcription polymerase chain reaction was used to determine viral genotypes using oligonucleotide generic primers that produce a 511 bp product. The resulting product was typed by nested PCR with strain-specific primers, yielding 482 (DEN-1), 119 (DEN-2), 290 (DEN-3) and 392 (DEN-4), visualized on UV transilluminator after electrophoresis on 2% agarose gel stained with ethidium bromide. Of 45 clinically diagnosed dengue patients (mean age 28 years; male/female 30/15), 19 (42.2%) had detectable viral RNA in their blood. However, during the first 5 days of fever in 30 patients, the frequency was 60% (18/30), implying that the sooner serum is drawn after the fever, the greater the chances of detecting viral RNA. DEN-3 was detected in all except 2 patients who were infected with DEN-2. DEN-2 (two cases) and DEN-4 (one case) were present as co-infections with DEN-3. All of the patients presented with fever, anorexia and vomiting; many had headache and general body ache; a few had a rash. About a quarter had suffered episodes of bleeding, while ascites, pleural effusion and CNS symptoms were found in a few patients Patients positive for viral RNA were also positive for anti-dengue IgM (p=0.007) in subsequent sampling. The study suggests the predominance of DEN-3 infection with occasional co-infection with other types, during the recent outbreak of dengue in Bangladesh.

Vegetarian diet in the treatment of fibromyalgia.

Brain tryptophan is low in fibromyalgia. Intake of protein rich in large neutral amino acids is reported to lower brain tryptophan. This study was undertaken to assess whether any reduction of such proteins by exclusion of animal protein from the diet reduced pain and morbidity in fibromyalgia patients. It was an open, randomized controlled trial. 37 subjects with fibromyalgia were enrolled in the vegetarian diet and 41 in the amitriptyline groups. The outcome was assessed with the help of frequencies of fatigue, insomnia & non-restorative sleep, pain score on a 10-point VAS and tender point count. Fatigue, insomnia and non-restorative sleep were present in 41, 26 and 32 subjects before and in 3, 0 and 0 subjects respectively at six weeks of treatment in the amitriptyline group. The pain score and tender point count were 6.2 +/- 1.9 & 16.1 +/- 2.3 before and 2.3 +/- 1.3 & 6.4 +/- 3.0 after treatment. All these differences were significant (P < 0.001). In the vegetarian diet group, fatigue, insomnia and non-restorative sleep were present in 36, 24 and 27 subjects before and in 34, 29 and 29 subjects at six weeks of treatment. The pain score and tender point count were 5.7 +/- 1.8 and 15.7 +/- 2.4 before and 5.0 +/- 1.8 & 14.7 +/- 3.6 after treatment. All these differences were insignificant except that in the pain score. The decrease in the pain score, though significant, was much smaller than that in the amitriptyline group. So, it may be concluded that vegetarian diet is a poor option in the treatment of fibromyalgia.

Efficacy of sulphasalazine plus methotrexate in rheumatoid arthritis.

Early intervention with slow acting anti-rheumatic drugs (SAARDs) has led to improvement in substantial proportion of rheumatoid arthritis (RA) patients. The present open, controlled study was designed to assess whether a combination of SAARDs offer any added benefit. Fifty-four adult RA patients were randomly allocated to methotrexate (MTX) (n = 27) and MTX plus sulphasalazine (SSZ) (n = 27) groups. The subjects were followed-up fortnightly for four weeks then monthly for six months. The disease activity was assessed with the help of 10 clinical and four laboratory indices. The improvement was graded as: minor, mild decreases in indices, non-steroidal anti-inflammatory drugs (NSAIDs) continued, physician's global assessment (PGA) decreased by one; marked, acceptable decreases in indices, NSAIDs being taken sparingly, PGA decreased by at least 2, and complete, all indices normalised and patients discontinued NSAIDs completely. The improvement was considered clinically important when marked or complete improvement occurred. Adverse drug reactions resulted in withdrawal of 4 subjects from the MTX + SSZ group and 1 from the control groups. Four and three subjects in the combined and MTX groups respectively were lost to follow-up. Subjects in both groups showed significant decline in all indices except hemoglobin and neutrophil count. The differences between the two groups in the pre-treatment and post-treatment values were insignificant. Complete, marked, minor and no improvement occurred in 4 (21%), 12 (63%), 3 (16%) & 0 in the MTX and in 11 (48%), 7 (30%), 4 (17%) & 1 (4%) in MTX + SSZ groups respectively. The differences in the rates of complete and clinically important improvement between the two groups were insignificant (P 0.1398 and 0.7092). The incidence of side effects was insignificantly higher in the MTX + SSZ group. Most of them were mild and transient. The combination of SAARDs offered little added advantage in RA. However, the higher rate of complete improvement in the combination group justifies trials including larger samples.

Efficacy of methotrexate in rheumatoid arthritis.

Rheumatoid arthritis is a common inflammatory articular disorder in Bangladesh. Methotrexate has proved to be an effective and relatively safe disease modifying drug for this disease. A quasiexperimental trial of the efficacy of methotrexate in rheumatoid arthritis was carried out in the Rheumatology Clinic, Institute of Postgraduate Medicine & Research, Dhaka during the period between July 1992 and September 1993. Thirty eight patients fulfilling the revised ARA criteria were given methotrexate in a total weekly dose of 7.5 to 15 mg. They were followed up at weekly intervals for one month and then monthly for a total duration of six months. Twenty three subjects eventually completed the trial. The trial showed significant differences in the disease activity indices at the end of six months. The decline of activity was noted at the end of one month. As a whole the response was complete in 4(17%), marked in 14(61%), moderate in 4(17%) and nil in 1(4%). Adverse effects occurred in 27 subjects. They were mild and transient in 22. Methotrexate appeared to be an acceptable DMARD for our rheumatoid arthritis population.

Value of clinical features in the diagnosis of enteric fever.

There is no objective data on the value of individual clinical symptoms or signs in the diagnosis of enteric fever in a febrile patient. The purpose of the study was to assess the value of some clinical and simple laboratory features in the diagnosis of enteric fever. One hundred & six patients with microbiologically confirmed enteric fever and 170 patients with other established febrile illnesses were included in the evaluation. History of stepladder pattern of rise of temperature, loose motions, relative bradycardia and coated tongue proved to be powerful markers of enteric fever with high specificity (100%, 94.71%, 94.71%, 94.12% respectively), positive and negative predictive values. Headache, hepatomegaly and splenomegaly were moderately powerful. ESR and WBC count appeared to have little value in the diagnosis of enteric fever. Pattern of onset and loose motions did not discriminate between typhoid and paratyphoid fever. Most of these patients had illness persisting beyond one week by which viral infections and infectious enterocolitides were largely excluded. Elucidation of power of these markers in distinguishing enteric fever from other febrile illnesses with the help of better designed prospective studies would lessen our dependence on expensive and time consuming laboratory investigations.

A study of prolonged pyrexia in Dhaka.

In a prospective study conducted in the Institute of Postgraduate Medicine & Research (IPGMR), Dhaka, 212 patients with prolonged pyrexia were thoroughly evaluated clinically and with the help of laboratory investigations with a view to reaching the diagnosis. Their clinical and laboratory data were recorded. Clinical features pertaining to a particular organ gave appropriate clue in 52% cases. Imaging techniques were instrumental in 24%, microbiological or serological investigations in 35%, invasive procedures were diagnostic in 42%, laparotomy had to be resorted to in five cases. Infectious diseases were the commonest causes of prolonged pyrexia accounting for about 63.21% of cases followed by neoplasms (12.74%) and connective tissue disorders (10.85%). Tuberculosis was the most common infection (24.53% of all cases) followed by enteric fever (12.74%) and visceral leishmaniasis (9.43%). Pleura was the commonest seat for tuberculosis followed by lymph nodes and abdomen. Leukemias were the commonest neoplasm and SLE the commonest connective tissue disorder presenting with prolonged fever. Several fundamental observations were made in the study. Infections are the commonest cause of prolonged fever in our community, neoplasms and connective tissue disorders are also not rare. Secondly, patients with temperature between 100 to 101 degrees F should not be denied evaluation with the apprehension of unnecessarily investigating for habitual hyperthermia, as the condition was distinctly rare in the series. Thirdly, analysis of materials from organs or systems suspected to be abnormal clinically or by simple imaging techniques had high diagnostic yield. Finally, usual causes of prolonged fever are illnesses ordinarily encountered in clinical practice, pyrexia becomes protracted either because the presentation is atypical or incomplete, or because we fail to make proper use of available clinical or paraclinical information.

Solitary thyroid nodule: a study of 100 cases.

One hundred cases of solitary thyroid nodules attending the thyroid clinic, Institute of Postgraduate Medicine & Research, Dhaka (IPGMR) and the Institute of Nuclear Medicine (INM) were included in a prospective study. Thyroid ultrasonography (USG), scintiscanning, radioactive iodine (I131) uptake (RAIU), estimation of serum total T3, T4 & TSH and Fine Needle Aspiration Cytology (FNAC) were performed in all cases. Surgical resection with histopathologic study was performed in selected cases. Extra-nodular part of the thyroid gland was normal in 68 and diffusely enlarged in 32, RAIU was normal in 62, high in 36 and very low in two subjects. Nodules were solid at USG in 67 subjects, cystic in 16 subjects and of mixed consistency in 17 subjects. Goitrous subjects had significantly lower T4 (p < 0.001) and higher T3 (p < 0.01) and TSH (p < 0.001) than non-goitrous ones. Colloid nodule was the commonest pathology occurring in 41 cases, followed by thyroid cysts (26), follicular adenoma (23), adenoma with cystic change (7), subacute thyroiditis (2) and papillary carcinoma (1). Colloid nodules were more common in goitrous subjects which could hint at iodine deficiency as the major cause of such nodules. Hyperfunctioning follicular adenomas occurred exclusively in non-goitrous subjects. Carcinoma appeared to be uncommon in patients with solitary nodules. It gives an opportunity to our physicians to be more conservative in selecting patients with solitary thyroid nodules for surgical treatment.

Role of a large plasmid in mediation of multiple drug resistance in Salmonella typhi and paratyphi A in Bangladesh.

From 405 patients of suspected typhoid fever, 94 Salmonella typhi and 17 Salmonella paratyphi A, were isolated from blood and/or stool at the Institute of Postgraduate Medicine and Research, Dhaka during March 1992 to February 1993. Forty seven percent of the isolates were resistant to multiple drugs which included amoxicillin, ampicillin, chloramphenicol and co-trimoxazole. A large plasmid of 140 MDa was isolated from 73% of multidrug resistant (MDR) strains. However, no plasmid was isolated from any of the strains sensitive to above mentioned antibiotics. Majority of MDR Salmonella transferred resistance to E. coli K-12 (Lac+, F-, NxR.) by conjugation method. The transconjugants were similarly resistant to multiple drugs. All Salmonella were sensitive to ciprofloxacin and ceftriaxone.

Comparative study of piroxicam and ibuprofen in rheumatoid arthritis.

Piroxicam was compared with ibuprofen in a 8 weeks randomised open clinical trial in 31 patients (16 patients with piroxicam and 15 patients with ibuprofen) with rheumatoid arthritis. Piroxicam was given in a dosage of 20mg once daily and ibuprofen 400mg three times a day. Both drugs appeared to be equally effective and there were only few minor side effects in patients on either drug. The once daily administration gives piroxicam a clear practical advantage over ibuprofen.

Dasherkandi project studies--health of the under fifteen.

Morbidity pattern of the under fifteen of a rural community was analysed and related to socio-economic factors. This was a part of Dasherkandi project studies carried out in a village near Dhaka city. 48.26% of the population was under the age of fifteen. Infants under the age of one year had low sickness rate which rose steeply between 1 and 4 years of life and then gradually declined after the age of 5 years. Commonest morbidity was worm infestation which was followed by flu and upper respiratory tract infection. The non-agriculturist and the low income group had the highest level of sickness. It is suggested that children in rural areas suffer mainly from diseases which are related to poor nutrition and hygiene resulting from unsatisfactory socio-economic condition. All the childhood mortality occurred under the age of one year and was found to be due to tetanus in this study.

Incidence of urethritis in Bangladesh.

Urethritis is either gonococcal or non-gonococcal. This paper describes the investigation of 286 cases of urethral or vaginal discharges, dysuria or urethral irritation. Non-gonococcal urethritis (NGU) was found to be the commonest form of urethritis accounting for 65.05 per cent of cases. Gonococcal urethritis (GU) and abacterial urethritis were accounted for 24.47 per cent and 10.48 per cent of cases respectively. No history of sexual exposure was found in 21.27 per cent of cases with NGU, whereas this was invariably present in cases of GU. This may indicate that in at least some of the patients with NGU, the disease may not be sexually transmitted. This point needs further study.

Dasherkandi project studies. Demography, morbidity and mortality in a rural community of Bangladesh.

The entire population of Dasherkandi, a village near Dacca city was surveyed. Out of 1181 people 44.2% suffered from organic or psychiatric disorders. 37.7% suffered from physical disorders, 3.6% suffered from psychiatric disorders and another 2.9% suffered from both psychiatric and physical disorders. The common physical disorders were worm infestations, hypertension, peptic ulcer, dental problems and upper respiratory tract infection including flu. Females suffered from psychiatric diseases more than males. The psychiatric morbidity found in the survey differed significantly from those found in other similar surveys. Depressive states were the commonest psychiatric disorder and women suffered four times as frequently as men. Anxiety neurosis was the next common psychiatric problem. Both crude mortality and infant mortality rates (5.75 and 93.20 per thousand respectively) were lower than those of other similar studies. The commonest cause of infant mortality during first one month of life was tetanus in this series. Inspite of the fact that diagnosis was based entirely on clinical findings the morbidity rate was high. It was observed that a high percentage of the people who suffered from psychiatric disorders were due to problems which can be easily tackled under field conditions.

A clinicopathologic study on patients suffering from "chronic dysentery".

Fifty adult patients with the self diagnosis of "chronic dysentery" were studied. Their faeces were examined microscopically; they were sigmoidoscoped and their rectal mucosa were examined histologically. Most of them had irritable bowel syndrome. Their sigmoidoscopic appearances were normal and the histology showed only mild increase in the numbers of round cells in the lamina propria. This was regarded as normal for the local population. Ten patients showed cysts of Entamoeba histolytica in the faeces. This was thought to be unrelated to the symptoms. Only four patients had sigmoidoscopic as well as histologic evidence of moderate to severe proctocolitis. One of them was proven to be a case of amoebic colitis. These findings have been discussed.

Psychiatric morbidity in general practice.

In order to estimate the psychiatric morbidity in patients asking for consultation with general practitioners, a study was carried out in a general practice in Dacca. This revealed a considerable psychiatric morbidity. The two most frequently encountered psychiatric conditions were neurotic and psychosomatic disorders.

Ulcerative colitis in Bangladesh.

A total of 100 cases with chronic diarrhoea having no apparent cause were investigated. Fifty seven of these cases fulfilled the diagnostic criteria of ulcerative colitis. Fortyone of these 57 patients were treated for acute amoebic dysentery during the initial episodes of their illness. Since attack of acute amoebic dysentery is liable to produce post-dysenteric ulcerative colitis, it is possible that ulcerative colitis exist in this country in at least 2 forms, idiopathic and post-dysenteric.