Scrub typhus meningoencephalitis presenting as opsoclonus myoclonus syndrome: A video-based case.

Opsoclonus myoclonus syndrome secondary to scrub typhus infection is a rare clinical entity. Hence, it is important to know its clinical manifestations and complications, so that it can be properly managed. We report a 28-year-old female whose initial manifestation was only fever, which subsided in four days. Two days later, she developed opsoclonus myoclonus syndrome. This was managed with doxycycline and clonazepam, but as it persisted, intravenous immunoglobulin was added. She showed excellent response to treatment.

Linezolid-Associated Posterior Reversible Leuco-encephalopathy Syndrome in a Patient with Disseminated Tuberculosis.

Neurological side-effects of linezolid manifesting as a posterior reversible leuco-encephalopathy syndrome (PRES) is rare. Early identification of this offending drug might reverse this catastrophic event. We report a 45-year-old female, who was diagnosed as a case of disseminated tuberculosis and was treated with antitubercular drugs (ATT), but later developed ATT-induced hepatitis. She was then put on modified ATT (moxifloxacin, terizidone, and linezolid). In the next two days she developed an altered sensorium. Brain imaging was suggestive of PRES. Linezolid was withdrawn, following which she showed an excellent clinical and radiological recovery.

An Unusual Case of Muscle Twitching: Its LGI1.

A 50-year-old male, presented with a two-months history of ascending paresthesias, with continuous twitchings over the body, associated with insomnia. His electromyography (EMG) revealed neuromyotonia and was diagnosed as a case of peripheral nerve hyperexcitability (PNH) syndrome due to Leucin-rich glioma-inactivated 1 (LGI1) antibody. He showed significant improvement with intravenous immunoglobulin and carbamazepine.

Urinary Calculi: A Microbiological and Biochemical Analysis at a Tertiary Care Hospital in Eastern Nepal.

BACKGROUND: The occurrence of urinary tract infection in presence of urolithiasis is frequently noted; however, microbial agents of urolithiasis and their antimicrobial susceptibility patterns remain underinvestigated. This study aimed to identify the microorganisms isolated from urine and stone matrices to determine their antimicrobial susceptibility, to find the association between the pathogens of urine and stone matrices, and to perform the biochemical analysis of stones. METHODS: A total of 88 cases of urolithiasis admitted for elective stone removal at Department of surgery, B.P. Koirala Institute of Health Sciences (BPKIHS), were enrolled. Preoperative urine culture and postoperative stone culture were performed. Isolation, identification, and AST were done by the standard microbiological technique. Further qualitative biochemical analysis of stones was also attempted. RESULT: Among 88 stone formers recruited, culture of urine, whole stone, and nidus yielded the growth of bacteria 44, 32, and 30, respectively. Bacteria isolated from urine culture correlated with those from stone matrices with a sensitivity of 90%, specificity of 79.69%, PPV of 63.64%, and NPV of 95.45%. Escherichia coli (46.7%) was the most common bacteria followed by Klebsiella pneumoniae (16.7%) and Proteus mirabilis (13.3%) from urine and stone cultures. Almost all the uropathogens isolated were susceptible to commonly used antibiotics. Calcium oxalate (84.1%) was common biochemical constituent found in stone formers followed by calcium oxalate + phosphate (8%). CONCLUSIONS: The association of microorganism isolated from urine and nidus culture was significant that can predict the source of infective stone; however, in some cases, microorganisms and the antimicrobial susceptibility pattern from urine and nidus were different. This study emphasizes the use of appropriate antimicrobial agents to prevent the regrowth of residual stones and minimize the risk of infectious complications after surgical removal of stones.

Aspirin and Clopidogrel Resistance in Indian Patients with Ischemic Stroke and its Associations with Gene Polymorphisms: A Pilot Study.

INTRODUCTION: Antiplatelet resistance is one of the urgent issues in current stroke care. One-third to one-half of the patients who experience a recurrent stroke is already on antiplatelet medications. We studied resistance to aspirin and clopidogrel in Indian stroke patients and its association with gene polymorphisms. METHODS: Platelet function testing by light transmission aggregometry was performed on 65 patients with ischemic stroke who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 75 mg OD) along with 65 age-matched controls. Aspirin resistance was considered as mean platelet aggregation ≥70% with 10 µM adenosine diphosphate (ADP) and ≥20% with 0.75 mM arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 µM and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19 * 2 and GPIIb/IIIa (PLA1/A2) were genotyped by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: We found 64.6% (42/65) patients with inadequate response to clopidogrel (15.4% [10/65] resistant and 49.2% [32/65] semi-responders) and 4.6% (3/65) patients with inadequate response to aspirin (3.1% [2/65] resistant and 1.5% [1/65] semi-responder). The frequency of CYP2C19*2 mutant genotype was significantly higher in clopidogrel nonresponders compared to responders (P = 0.014). Clopidogrel nonresponsiveness was much higher in small vessel stroke. CONCLUSION: Unlike aspirin, a high proportion of nonresponders to clopidogrel was identified. In an interim analysis on 65 Indian patients, a significant association was found between CYP2C19*2 and clopidogrel nonresponsiveness.

Laparoscopic Choledochotomy in a Solitary Common Duct Stone: A Prospective Study.

BACKGROUND: Laparoscopic common bile duct exploration has all the advantages of minimal access and is also the most cost effective compared to the other options. OBJECTIVE: To study a profile on laparoscopic common bile duct exploration for a single common duct stone. METHODS: A total of 30 consecutive patients with solitary common bile duct stone attending our hospital over a period of one year were enrolled in the study. Laparoscopic common bile duct exploration was done by transductal route in all the patients. RESULTS: There were 18 females and 12 males with age ranging from 28 to 75 years. Jaundice was present in 12 (40%) patients. Twenty-four (80%) patients had raised alkaline phosphatase. The mean size of CBD on ultrasound was 11.55 mm. The mean size of calculus was 11.06 mm and was located in the distal CBD in 26 (86.7%) patients. The mean operative time was 158.4 ± 57.89 min. There were 8 (26.6%) conversions to open procedure. T-tube was used in 26 (86.7%) patients. The postoperative complications were hospital acquired chest infection in 3 (10%), surgical site infection in 3 (10%), acute coronary syndrome in one (3.3%), and bile leak after T-tube removal in one (3.3%) patient. CONCLUSIONS: Laparoscopic common bile duct exploration is an effective, safe management of common bile duct stone.

Cryptococcal Infection in Transplant Kidney Manifesting as Chronic Allograft Dysfunction.

Invasive fungal infections (IFIs) are a significant cause of morbidity in solid organ transplant (SOT) recipients. Common causes among them are Aspergillus, Candida, and Cryptococcus. Antifungal prophylaxis has led to decrease in overall incidence of IFI; however, there is very little decline in the incidence of Cryptococcal infections of SOT recipients because effective prophylaxis is not available against this infectious agent. Spectrum of manifestation of Cryptococcal infection varies in immunocompetent and immunocompromised host with subclinical and self-limiting with lungs being the primary site in immunocompetent and central nervous system as the most common site in an immunocompromised host. Other preferred sites are cutaneous, pulmonary, urinary tract (prostate) and the bone. Herein, we describe a young adult renal transplant recipient male diagnosed as a rare case of biopsy proven Cryptococcal infection in transplant kidney manifesting as chronic allograft dysfunction.

Meningitis with polymerase chain reaction for varicella zoster positivity in cerebrospinal flid of a young immunocompetent adult.

Meningitis caused by varicella zoster virus (VZV) is quite rare among young immunocompetent adults though immunocompromised patients are often seen to be affected by reactivation of VZV presenting with primary clinical features of dermatomal rashes and neurological sequelae. Here, we report the clinical scenario of a young, healthy male who had presented with fever, headache, and onset of dermatomal rashes later than the fever and was eventually diagnosed to be a case of VZV meningitis. We would like to highlight the fact that even young immunocompetent patients though rarely, might contract VZV meningitis and clinicians should have a high index of suspicion and keen eyes to catch the more obvious features of VZV infection on complete physical examination and must not harbor any reservations in ordering polymerase chain reaction for VZV DNA or initiating aggressive antiviral therapy.

Biocompatibility of common polyimides with human endothelial cells for a cardiovascular microsensor.

The cardiovasculature is an emerging niche for polyimide microdevices, yet the biocompatibility of polyimides with human endothelial cells has not been reported in the literature. In this study, we have evaluated an experimental polyimide-based pressure sensor for biological safety to determine its suitability for intravascular operation by using an in vitro model of human endothelium, following ISO 10993-5 protocols for extract tests and direct contact tests. First, SV-HCEC cells were incubated with extracts derived from common microfabrication polyimides utilized in the transducer (PMDA-ODA, BPDA-PPD, and a proprietary thermoplastic adhesive), and then labeled with selective probes to evaluate the effect of the polyimides on mitochondria and cell viability. Flow cytometry analysis showed that incubation of SV-HCECs with polyimide extracts resulted in no significant change in mitochondrial membrane potential (detected by JC-1) or apoptotic (annexin V) and necrotic (propidium iodide) cell death, when compared to incubation with extracts of high-density polyethylene (HDPE) and untreated cells used as negative controls. Second, primary human endothelial cells were incubated in direct contact with the completed sensor and then labeled with selective probes for live-dead analysis (calcein-AM, ethidium homodimer-1). Endothelial cells showed no loss of viability when compared to negative controls. Combined, the studies show no significant change in early markers of stress or more strict markers of viability in endothelial cells treated with the polyimides tested. We conclude that these common microfabrication polyimides and the derived sensor are not cytotoxic to human endothelial cells, the primary cell type that cardiovascular sensors will contact in vivo.

Superbugs causing ventilator associated pneumonia in a tertiary care hospital and the return of pre-antibiotic era!

The rise in super bugs causing Ventilator-Associated Pneumonia (VAP) is a major cause of mortality and morbidity despite recent advances in management owing to the looming 'antibiotic apocalypse'. The aetiology and susceptibility pattern of the VAP isolates varies with patient population, type of intensive care unit (ICU) and is an urgent diagnostic challenge. The present study carried out for a period of one year in a tertiary care hospital, enrolled patients on mechanical ventilation (MV) for ≥48 hrs. Endotracheal aspirates (ETA) from suspected VAP patients were processed by semi quantitative method. Staphylococus aureus, members of Enterobacteriaceae were more common in early onset VAP (EOVAP), while Nonfermenting Gram negative bacilli (NFGNB) were significantly associated with late onset VAP (LOVAP). Most of the isolates were multi drug resistant (MDR) super bugs. With limited treatment options left for this crisis situation like the pre-antibiotic era; it is an alarm for rational antibiotic therapy usage and intensive education programs.

Interleukin-6 (IL-6)-597 A/G (rs1800797) & -174 G/C (rs1800795) gene polymorphisms in type 2 diabetes.

BACKGROUND & OBJECTIVES: Diabetes is a metabolic pro-inflammatory disorder characterized by chronic hyperglycaemia and increased levels of circulating cytokines suggesting a causal role for inflammation in its aetiology. In order to decipher the role of interleukin-6 (IL-6) in type 2 diabetes mellitus (T2DM) we analyzed two promoter polymorphisms -597 A/G (rs1800797) and -174 G/C (rs1800795) in T2DM cases from north India, and in healthy controls. METHODS: DNA was isolated from venous blood samples of T2DM patients (n=213) and normal healthy controls (n=145). Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed after biochemical analysis. The genotypic and allelic frequency distributions were analyzed. RESULTS: The clinical/biochemical parameters of T2DM cases when compared to controls showed a significant difference. No significant association was observed with -597A/G polymorphism while, -174 G/C showed a highly significant association (P<0.001). In haplotypic analysis, combination of -597GFNx01/-174CFNx01 showed significant association (P=0.010). INTERPRETATION & CONCLUSIONS: Our data suggest that IL-6 gene polymorphisms play a prominent role in T2DM disease susceptibility in population from north India.

Mixed pulmonary infection in an immunocompromised patient: a rare case report.

Patients who are immunocompromised are predisposed to a variety of common and uncommon pulmonary infections. We report a case of mixed pulmonary infection by drug resistant tuberculosis with a nocardiosis in a 49-year-old man who was a known case of chronic obstructive pulmonary disease, on prolonged corticosteroid use with diabetes mellitus. Chronic use of corticosteroids is a predisposing factor for opportunistic infections, such as nocardiosis or tuberculosis. Since such a mixed infection is rare, maybe a combined approach to therapy early in the course of disease would be effective in such cases.

Drug susceptibility of matrix-encapsulated Candida albicans nano-biofilms.

The rise in the use of biomedical devices and implants has seen a concomitant surge in the advent of device-related nosocomial (hospital-acquired) infections of bacterial and fungal origins. The most common nosocomial fungal infection is candidiasis caused mainly by Candida albicans biofilms. Candidiasis is associated with an unacceptably high mortality rate, and there is an urgent need for the discovery of new antifungal drugs that prevent or control biofilm formation. To this end, we recently developed an ultra-high-throughput microarray platform consisting of nano-scale biofilms of C. albicans encapsulated in collagen or alginate hydrogel matrices for antifungal drug screening. Here, we report that the choice of matrix influences the apparent susceptibility of C. albicans to the common antifungal drugs, amphotericin B, and caspofungin. While amphotericin B is equally effective against biofilms grown in collagen and alginate matrices, caspofungin is effective only against biofilms grown only in alginate, but not in collagen. We demonstrate differences in the distribution of the drugs in the two matrices may contribute to the susceptibility of C. albicans nano-biofilms. In a larger context, our results highlight the importance of the choice of matrix as a parameter in 3D cell encapsulation, and suggest a screening strategy to predict drug performance in vivo.

Bile duct injuries during open and laparoscopic cholecystectomy: management and outcome.

BACKGROUND: The widespread application of laparoscopic cholecystectomy has led to a rise in the numbers of major bile duct injuries (BDI). Perioperative management of these injuries is complex and challenging. There are few published reports locally regarding the perioperative management of BDI. Purpose of this review was to analyze our experience in diagnosis, management and prevention of BDI. METHODS: This study was conducted in department of surgery at B. P. Koirala Institute of Health Sciences. From January 2001 to September 2010, a observational study of all patients with a BDI following cholecystectomy was maintained. Patients' charts were retrospectively reviewed to analyze incidence, type of injury, presentation, and perioperative management of BDI. RESULTS: A total of 92 patients had BDI which occurred during cholecystectomy, were analysed retrospectively. There were 60/92 (65.5%) patients with BDI resulting from the wrong identification of the anatomy of the Calot's triangle during cholecystectomy. Abdominal ultrasonography was diagnostic for BDI in 71/90 (78.8%). Magnetic resonance cholangiography could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 22/23 (95.6%). The most common injury was Strasberg's E2 in 65/92 (70.7%). A transection or stricture of the bile duct was repaired by hepaticojejunostomy (83 cases in this series). Seventy-five (81.5%) patients were followed up. The mean follow-up time was 2.6 years (range 0.16-6). Good results were achieved in 62/75 (82.6%) of the patients. CONCLUSIONS: The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Examination of relationship of scores obtained in grades 10 and 12 with the entry and success in undergraduate medical education.

BACKGROUND: Entrance examination (admission test) is the most important and widely accepted method of student selection for admission into medical schools in Nepal. For many schools it is the only criterion of student selection. OBJECTIVES: To examine relationships of scores obtained in schooling (grade 10 and 12), medical entrance and MBBS professional examinations in a cohort to identify predictive strength for entry into medical school and success in medical education. METHODS: Exam scores from grade 10 to medical entrance and professional exams of undergraduate medical education of a total of 118 medical students who entered medical school between 1994 and 1998 only through the merit of open competitive medical entrance examination at the BP Koirala Institute of Health Sciences (BPKIHS) were assessed. RESULTS: Student selection for admission in MBBS course at BPKIHS and their subsequent success were not determined by difference in outcomes of public and private management of schools at grade 10 (selection p= 0.80 and success p= 0.32 ) and grade 12 (selection p= 0.59 and success p= 0.55). Grade 12 averaged scores had no relationship in getting these students selected for admission into medical course (r= 0.08, p= 0.37), but did show correlation with the overall success in medical education (r= 0.32, p= 0.00). Scores in physics at grade 12 retained predictive strength in success in medical education (r= 0.19, p= 0.04). CONCLUSION: The present student selection criteria for medical education are not appropriate and need to incorporate other attributes of candidates along with cognitive aspects.

An interleukin-10 gene promoter polymorphism (-592A/C) associated with type 2 diabetes: a North Indian study.

In this first report on the association of an IL-10 promoter polymorphism with type 2 diabetes mellitus in a North Indian population, the -592A/C SNP (rs1800872) was genotyped by PCR-RFLP and the IL-10 level measured using ELISA. Although no significant difference was observed in the genotypic frequencies (P = 0.657), diabetes patients carried a significantly higher number of A alleles at the -592 position, 25.6% (P < 0.001, odds ratio 0.887, 95% CI 0.670-1.184). Significant correlations were detected in postprandial glucose levels of CC-genotype patients and controls (P = 0.025), age and waist-hip ratio of CA patients and controls (P ≤ 0.001), and fasting glucose (P = 0.045) and low-density lipoprotein (P = 0.049) in all patients and controls. The serum IL-10 level was significantly higher in patients than in controls (P = 0.033). The polymorphism was significantly associated with disease incidence and its biochemical manifestations.