Hot and cold: coexistent Graves' disease and Hashimoto's thyroiditis in a patient with Schmidt's syndrome.

A 37-year-old housewife presented with generalised fatigue, palpitations and weight loss over the past 3 months. Physical examination revealed signs of hyperthyroidism. Thyroid function tests confirmed the presence of thyrotoxicosis. Pertechnetate radionuclide imaging of the thyroid showed diffusely increased radiotracer uptake consistent with Graves' disease and a cold nodule in the right lobe. Needle aspiration from the nodule yielded evidence of Hashimoto's thyroiditis. The patient also tested strongly positive for antithyroid peroxidase antibodies. Simultaneous laboratory evaluation revealed primary adrenal failure and probable pernicious anaemia, thus producing a diagnosis of Schmidt's syndrome. The patient was initiated on appropriate medical therapy for endocrinopathy. Graves' disease was treated with radioablation.

Primary presentation of chronic calcific pancreatitis with massive unilateral pleural effusion.

We described a 45-year-old previously healthy man presenting with progressively worsening breathlessness for 10 days. Physical examination was suggestive of a left-sided pleural effusion. A chest X-ray was confirmatory. Analysis of aspirated fluid showed a lymphocytic exudate with grossly elevated amylase and lipase levels. CT revealed chronic calcific pancreatitis as the underlying cause of effusion. Retrospective questioning failed to identify classical symptoms of chronic pancreatitis including abdominal pain and steatorrhoea. The patient was managed with intercostal drainage and supportive care. Although unusual, chronic pancreatitis should be kept as a differential diagnosis in patients with unilateral exudative pleural effusion. Elevated fluid levels of amylase and lipase are useful clues to this uncommon diagnosis.

A novel subtype of myeloproliferative disorder? JAK2V617F-associated hypereosinophilia with hepatic venous thrombosis.

We report the case of a 27-year-old man, presenting with one episode of massive haematemesis and a history of persistent eosinophilia for the past 8 months. An evaluation revealed hepatic cirrhosis with portal hypertension, secondary to chronic Budd-Chiari syndrome. Further investigations confirmed a diagnosis of hypereosinophilic syndrome. Molecular genetic analysis was negative for FIP1L1-PDGFRA gene rearrangement, but positive for JAK2V617F mutation.

Brucellosis and tuberculosis: clinical overlap and pitfalls.

OBJECTIVE: To identify characteristic features of tuberculosis in patients with culture proven brucellosis. METHODS: A retrospective analysis was performed on patients diagnosed with culture proven brucellosis between January and December 2011, based on review of their medical records. Patients with demonstrable co-infection with tuberculosis were excluded. Clinical features, laboratory parameters and tissue histopathology reports where available were noted. RESULTS: Thirty-two patients with brucellosis were included in the study. Twenty-one (65.63%) patients had chronic fever, thirteen (40.63%) had a productive cough, while significant weight loss, evening rise of temperature and night sweats were reported by eight (25.00%), eleven (34.38%) and five (15.63%) patients respectively. Nine (28.13%) patients had at least three of these symptoms. Lymphadenopathy, hepatomegaly and splenomegaly were noted on examination in seven (21.88%), fifteen (46.88%) and twelve (37.50%) patients respectively. Eight (25.00%) patients had hepato-splenomegaly, of these only two had associated significant lymphadenopathy. Respiratory examination was normal in all patients. Elevated ESR greater than 50 mm/hr was seen in eight (25.00%), it was greater than 100 mm/hr in five (15.63%) patients. Hypergammaglobulinemia was seen in eight (25.00%) cases. Bone marrow biopsy showed non-caseating granulomas in three (9.38%) cases, lymph node biopsy showed granulomas in one case. Overall, three (9.38%) patients had known risk factors for tuberculosis, while six (18.75%) had risk factors for brucellosis. CONCLUSIONS: There is a clear overlap between brucellosis and tuberculosis both in terms of clinical presentation and laboratory parameters. It is essential to carefully rule out tuberculosis in all cases of suspected or proven brucellosis before initiating antimicrobial therapy, in order to forestall development of drug-resistant tuberculosis.

Severe unconjugated hyperbilirubinaemia: one and one makes three?

A 38-year-old housewife presented with a 3-month history of gradually progressive fatigue and deepening jaundice as well as a history of mild fluctuating jaundice since childhood. General examination revealed an obvious icterus. Systemic examination was normal. Laboratory tests confirmed unconjugated hyperbilirubinaemia. Further evaluation yielded a diagnosis of vitamin B12 deficiency on a background of Gilbert's syndrome.

HIV-tuberculosis co-infection in an Indian scenario: the role of associated evidence of immunosuppression.

OBJECTIVE: To determine the relationship between tuberculosis and the degree of immunosuppression as determined by CD4 count. The impact of immunosuppression on the severity of tuberculosis was also studied. METHODS: A retrospective analysis was performed in patients newly diagnosed with HIV infection and antiretroviral therapy (ART)-naive patients with known HIV seropositivity. All patients were diagnosed with active tuberculosis between January 2008 and December 2010, based on review of their medical records. Patients on chemoprophylaxis for opportunistic infection were excluded. Pattern and severity of tuberculosis, associated stigmata of immunosuppression, and CD4 counts were noted. RESULTS: Of 140 patients satisfying the inclusion criteria, 52 had mild tuberculosis with no other evidence of immunosuppression, 52 had tuberculosis of variable severity with associated evidence of immunosuppression, and 36 had severe tuberculosis with no other evidence of immunosuppression. The CD4 count was highest in the first group [(109.2±99.9) cells/µL] and least in the second group [(58.4±39.8) cells/µL], and the difference was statistically significant (P=0.004). No statistical difference was observed in the CD4 count between those with mild tuberculosis and those with severe tuberculosis. CONCLUSIONS: In developing countries with a high prevalence of tuberculosis in the general population, the possibility of incidental tuberculosis in patients with HIV should always be considered. CD4 count does not appear to influence the severity of tuberculosis. The presence of concomitant evidence of immunosuppression in the form of category B and C conditions is indicative of underlying immunosuppression and associated with a significantly lower CD4 count.

Disseminated tuberculosis presenting with secondary haemophagocytic lymphohistiocytosis and Poncet's disease in an immunocompetent individual.

We report a 27-year-old previously healthy man, who presented with fever and painful swelling of both ankles for 6 months, and who had been jaundiced for 1 week. Clinical examination revealed diffuse macular rash, severe pallor, deep icterus, generalised lymphadenopathy and hepatosplenomegaly. Detailed evaluation revealed granulomata in bone marrow aspirate, and numerous acid fast bacilli in lymph node biopsy. Bone marrow PCR was also positive for Mycobacterium tuberculosis. A diagnosis of disseminated tuberculosis was made and antitubercular therapy was initiated. Investigation also showed features of haemophagocytosis within the bone marrow. Results of further tests satisfied the criteria for haemophagocytic lymphohistiocytosis, probably secondary to tuberculosis. However, rapid deterioration in his clinical condition led to his death within 5 days of diagnosis, before appropriate therapy for haemophagocytic lymphohistiocytosis could be instituted. This case report highlights an unusual and deadly presentation of tuberculosis in an immunocompetent individual.

Primary presentation with acute flaccid quadriparesis in Sjogren's syndrome sans sicca.

We report the case of a 40-year-old housewife, who presented with vomiting since past 5 days and weakness of all four limbs since 1 day. Clinical examination confirmed the presence of flaccid quadriparesis with preserved tendon reflexes. Routine laboratory parameters showed severe hypokalaemia. On further evaluation she was diagnosed to have type 1 renal tubular acidosis secondary to Sjogren's syndrome. Sicca symptoms were conspicuous by their absence.

Primary abdominal nocardiosis masquerading as tubercular pelvic inflammatory disease in an immunocompetent individual.

We report the case of a 30-year-old housewife who presented with fever and lower abdominal pain, and was diagnosed with an adnexal collection. Initial evaluation was suggestive of tubercular pelvic inflammatory disease (PID). Subsequently, from a culture of pus aspirated from the collection grew out Nocardia species. She was treated with amikacin and cotrimoxazole and made a complete recovery. Clinical and laboratory evaluation for immunosuppression was negative. Primary abdominal nocardiosis is an unusual cause for PID and an important differential diagnosis for tuberculosis.

An unusual cause for recurrent jaundice in an otherwise healthy male.

A 41-year-old Asian-Indian male presented with recurrent episodes of jaundice over the past six months. Physical examination was normal, barring mild icterus. Laboratory parameters revealed indirect hyperbilirubinemia. Further evaluation yielded a diagnosis of severe nutritional vitamin B12 deficiency. Indirect hyperbilirubinemia was ascribed to ineffective erythropoiesis. Underlying Gilbert's syndrome was ruled out by provocative testing with lipid-restricted diet. Presentation of severe vitamin B12 deficiency with isolated hyperbilirubinemia without concomitant major haematologic or neurologic dysfunction is unusual and potentially underdiagnosed. Awareness of this possibility can permit early diagnosis of vitamin B12 deficiency and forestall development of severe haematologic and neurologic sequelae.

Cranial melioidosis with extradural extension after a fall in the bathroom.

A 32-year-old diabetic male, with a past history of head injury and seizures, presented with a painful swelling over his forehead present for the past three months. Cranial MRI demonstrated the presence of a scalp collection with extradural extension through a bony defect. Biopsy from the area showed caseating necrosis suggestive of tuberculosis. Although the patient failed to return for initiation of anti-tubercular therapy for the next 11 months, the swelling did not progress, and there were no constitutional symptoms. The indolent nature of the swelling prompted re-evaluation and delayed cultures of pus from the collection grew Burkholderia pseudomallei.

Vitamin B12 deficiency: an unusual cause for recurrent generalised seizures with pancytopaenia.

We report the case of a 70-year-old man with pancytopaenia and new-onset recurrent generalised seizures. Detailed evaluation yielded a diagnosis of vitamin B(12) deficiency. He was treated with parenteral vitamin B(12) supplementation and antiepileptic drugs. Seizures are an unusual manifestation of vitamin B(12) deficiency and possible mechanisms of epileptogenesis are discussed.

A rare case of seronegative culture--proven infection with Brucella suis.

Brucellosis is a chronic infection produced by members of the Brucella family. Diagnosis of this condition requires either isolation of the organism in culture or positive serological tests.We describe a 27-year-old male admitted as a case of pyrexia of unknown origin (PUO), who tested negative for Brucella IgM ELISA test on preliminary evaluation but was subsequently diagnosed on the strength of positive blood and bone marrow cultures to be a case of brucellosis secondary to Brucella suis infection. In addition to highlighting the pathogenic potential of an unusual organism, this case demonstrates the unreliability of standard serological tests based on the Brucella melitensis antigen for infection with other species of Brucella.

Polymyositis-like syndrome with rhabdomyolysis in association with brucellosis.

Diffuse myositis with progression to rhabdomyolysis has been reported in association with wide range of viral infections. We report a case of polymyositis-like syndrome complicated by rhabdomyolysis secondary to brucellosis. This case report thus contributes yet another atypical presentation to a disease already infamous for its protean manifestations.

Ketosis-prone type 2 diabetes mellitus in a patient with Sheehan's syndrome: a rare convergence of two distinct endocrine entities.

A 36-year-old housewife, previously diagnosed with Sheehan's syndrome on glucocorticoid and thyroxine replacement therapy, presented with unprovoked diabetic ketoacidosis. Ketoacidosis was corrected with intravenous fluids and insulin therapy. Further evaluation was suggestive of type 2 diabetes mellitus. On follow-up, she experienced repeated episodes of hypoglycaemia and insulin was tapered and stopped. Adequate glycaemic control was maintained with metformin monotherapy.

Tuberculous mediastinal abscess as a paradoxical reaction in an immunocompetent individual.

A 22-year-old man, diagnosed 7 weeks before with pulmonary tuberculosis and started on antitubercular therapy, presented with non-exertional retrosternal chest pain since the past week. He was diagnosed on the strength of thoracic radiograms and CT imaging to have a mediastinal abscess, which was percutaneously drained. He was continued on the same regimen of drugs. Analysis of the fluid obtained was suggestive of tuberculous aetiology. Steroids were not required.

An unusual cause for hyponatremia with seizures.

A 50-year-old Asian Indian female with known hypertension presented with persistent vomiting but no other symptoms of meningism. Clinical examination and basic laboratory parameters were entirely normal except for significant hyponatremia. Further investigation was suggestive of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Subsequently, despite steady correction of hyponatremia, the patient developed generalised seizures. Cerebrospinal fluid (CSF) analysis performed was inconclusive. Screening for a chronic meningitis underlying SIADH, yielded positive blood and CSF titres for venereal disease research laboratory (VDRL), which were confirmed by Treponema pallidum haemagglutination (TPHA). The patient was treated for neurosyphilis and made a complete recovery. Hyponatremia resolved and she had no further episodes of seizures. She was tested for HIV infection which was negative. On follow-up, she remained TPHA positive but VDRL titres became negative.

Spectrum of complications associated with Plasmodium vivax infection in a tertiary hospital in South-Western India.

OBJECTIVE: To determine the range and incidence of complications associated with Plasmodium vivax (P. vivax) malaria. METHODS: A retrospective analysis was performed of all patients of P. vivax malaria admitted in Kasturba Medical College, Manipal between January and December, 2010. Patients with mixed malarial infection were excluded by appropriate tests. Clinical presentation and laboratory parameters were studied. RESULTS: Medical records of 213 individuals who satisfied the inclusion criteria were reviewed. Anaemia was seen in 65 (30.5%), leucopenia in 38 (17.8%) and thrombocytopenia in 184 (86.4%) patients. Aspartate and alanine aminotransferases were elevated in 86 (40.4%), and 89 (41.9%) patients respectively. Hypoalbuminemia was observed in 157 (73.6%) cases. Elevated serum creatinine was noted in in 59 (27.5%) patients. Creatine kinase was elevated in 30 out of 59 patients (50.8%). Overall, 107 (50.2%) patients fulfilled WHO criteria for severe malaria. None of the patients succumbed to the disease. CONCLUSIONS: P. vivax malaria is a potentially severe disease, and the term "benign" tertian malaria is a misnomer. Despite significant morbidity, with timely and appropriate treatment P. vivax malaria has an excellent outcome.