An unusual cause for sicca syndrome.

We present a case of a 47-year-old female who presented with sicca symptoms since three months. As per the Revised International Classification Criteria for Sjögren's syndrome, patient was diagnosed as primary Sjögren's syndrome (SS). Patients with SS are known to have circulating monoclonal immunoglobulins. Serum electrophoresis revealed M band with serum gamma globulin concentration of 46 g/L. Bone marrow aspiration revealed 28% plasma cells. In absence of myeloma-related organ damage, a diagnosis of smouldering myeloma (MM) was made. Patient was treated with thalidomide and dexamethasone. Sicca symptoms resolved with anti-myeloma treatment. Although MM can occur as a complication of SS, MM can also rarely present as SS. In the present case, the short duration of sicca symptoms and response of these symptoms to anti-myeloma treatment support the diagnosis of MM presenting as SS. The present case highlights the importance of serum electrophoresis in patients presenting as SS.

Primary hypoparathyroidism: psychosis in postpartum period.

We report a 30-yr-old lady who was being treated as postpartum psychosis. Patient had generalized tonic clonic convulsions and was found to have bilateral cataract. Her serum calcium, serum magnesium and serum parathyroid were low. On correction of serum magnesium her PTH did not increase. She was hence diagnosed as primary hypoparathyroidism. On correction of her serum calcium her psychosis improved.

Infective endocarditis in a child masquerading as vasculitis: case report.

Since both vasculitis syndromes and infective endocarditis may present with multi-system involvement, they can pose a diagnostic dilemma. A 10-year-old boy was admitted with multi-system disease secondary to embolic complications of infective endocarditis. Echocardiography demonstrated mitral valve prolapse and moderate mitral regurgitation with vegetations on the anterior and posterior mitral leaflet. Despite supportive treatment, his general condition deteriorated and he died 3 days after admission.

Brucella spondylitis and sacroiliitis in the general population in Mumbai.

OBJECTIVE: 1) To identify patients of brucella spondylitis and sacroiliitis amongst patients of 'infective spondylitis' and 'sacroiliitis', 2) To study clinical and radiographic features and outcome of brucella spondylitis. METHODS: We reviewed 21 patients of infective spondylitis and 12 of sacroiliitis attending our hospital between March and September 2000 and followed them to identify patients of brucella spondylitis and brucella sacroiliitis, using serological tests. RESULTS: 1) Twenty six patients (17 spondylitis and nine sacroiliitis) were detected to have brucella infection to be the cause of their illness. 2) Brucella spondylitis is commonly mistaken for tuberculous spondylitis in our country. Thus leading to a delay in the diagnosis as well as occurrence of angular deformity and neurological deficit, which are reportedly uncommon in this condition. 3) Consumption (or handling) of unpasteurized milk (tabela milk) and occasional animal contact were found to be the source of infection in the general population. 4) Predominantly lumbar spine involvement, end-plate erosion of L4, L3, L5, decreased intervertebral disc space, repair with'formation of an osteophyte, simultaneous involvement of several sites and association of spondylitis with sacroiliitis were important radiographic features. CONCLUSIONS: Brucellosis exists in the general population, high clinical suspicion especially when there is history of animal contact or consumption of unpasteurized milk, familiarity with clinical and radiological features of brucella spondylitis and detection of antibodies to brucella by ELISA will help us detect and treat these patients in time.

Celiac disease in osteoporotic Indians.

OBJECTIVE: 1) The aim of the study was to identify the atypical celiac disease (CD) in a cohort of symptomatic osteoporotic patients, younger than 55 years of age and 2) To study associated clinical and laboratory features and outcome with gluten-free diet. MATERIAL AND METHODS: We studied 33 patients (F:M = 28:5), mean age 29 years (range 15-52 years) with osteoporosis (WHO diagnostic criteria, T-score less than -2.5 on DEXA scan) from January 2000 - June 2002. Serological screening for CD was done by detecting circulating IgA antibodies to tissue transglutaminase by ELISA. Patients with presence of antibodies to transglutaminase were subjected to biopsy from the 2nd part of the duodenum by upper GI endoscopy. The biopsies were reported independently by two pathologists who were blinded for the serology report. Measurement of mucosal thickness, crypts and villi were done with an ocular micrometer. Other parameters like complete hemogram, serum iron, total iron binding capacity (TIBC), calcium profile, 25-OH-D, parathyroid hormone (PTH) were evaluated. Assessment of clinical and laboratory parameters was performed within 4-12 weeks of starting gluten-free diet (GFD). RESULTS: Thirteen patients had circulating IgA antibodies to transglutaminase. Intestinal biopsies were performed on 11 patients and were consistent with the diagnosis of CD (total villous atrophy--two, subtotal villous atrophy with crypt hyperplasia--nine). Patients with CD had significant anaemia when compared with non-CD osteoporotic patients. Other important observations in these 11 patients were low serum calcium and phosphorus, low 25-OH-D, high PTH. Significant improvement in clinical and laboratory parameters was noted in all patients within 6-12 weeks of starting GFD. CONCLUSION: Symptomatic osteoporotic patients (younger than 55 years of age) especially with associated anaemia should be investigated for CD. Simple measures like omission of wheat from diet (GFD) lead to significant improvement in symptoms within weeks.

Quadriplegia complicating ossification of the posterior longitudinal ligament.

We report a case of quadriplegia complicating ossification of posterior longitudinal ligament (OPLL) in a patient who was also found to have diffuse idiopathic skeletal hyperostosis (DISH). She also had osteomalacia (Vit. D deficiency) with secondary hyperparathyroidism. There could be a cause and effect relationship between the abnormal biochemistry and OPLL.

Angiosarcoma of the heart presenting as recurrent cardiac tamponade.

We present an interesting case of angiosarcoma of the heart presenting as recurrent percardial effusion and cardiac tamponade.

Disseminated cryptococcal infection in immune competent patients.

Cryptococcal meningeal or cerebral infection has become an increasing global problem.(1) In this respect there are many anacedotal Indian case reports.(2) More than 50% of CNS infections occur in immunosuppressed patients and other debilitating conditions. Neurological form of cryptococcosis in immunocompetant patients needs to be considered in situations with intractable headache, papilloedema, hydrocephalus and prior to decisions on shunt placements.(3) We report on two such immunocompetent patients who presented with CNS involvement. Their clinical features and outcome is discussed.

Plasmapheresis: an adjunct therapy in severe progressive neuropsychiatric lupus.

OBJECTIVE: We report our experience with use of plasmapheresis (PP) as an adjunct therapy in severe progressive neuropsychiatric systemic lupus erythematosus (NPSLE). METHOD: Three patients of NPSLE (including 2 with status epilepticus) who were progressively worsening on steroids or combination of pulse cyclophosphamide (CPM) and steroids were treated with PP followed by synchronized CPM. Pre and post treatment SLE Disease Activity Index (SLEDAI) and laboratory tests were carried out. RESULTS: Significant clinical improvement with decrease in SLEDAI occurred immediately following PP. Mean SLEDAI before and after PP were 33 and 11. Mean erythrocyte sedimentation rate decreased from 121 to 31. Rebound flare of disease activity noted in two patients between 7th-10th day requiring additional immunosuppressants or steroids. CONCLUSIONS: PP used as an adjunct therapy in severe, progressive NPSLE is well tolerated and can turn the patient around. PP should be followed by synchronized pulse CPM to prevent disease flare.

Retrospective treatment analysis of Salmonella infections.

Twenty four culture proved and nine postmortem histopathology proved cases of enteric fever were analysed retrospectively with special interest in use of various antisalmonella agents. Chloramphenicol resistance was noted in 91.7% and yet 70% of all patients received chloramphenicol alone or in combination with another antisalmonella agent. Time required for remission of fever with chloramphenical, cotrimoxazole and ciprofloxacin was 4.5, 4.1 and 6.9 days respectively. An interesting feature noted in post-mortem histopathology proved cases was enteric carditis which was documented on postmortem examination of the heart in three out of four patients who died of peripheral circulatory failure.

Rhabdomyolysis and acute renal failure following a single dose of succinylcholine.

A 30-year old with rhabdomyolysis and acute renal failure is presented. The attack followed a minor operation under general anaesthesia during which succinylcholine was administered as muscle relaxant. The fasciculations which occurred immediately after injection of succinylcholine may possibly have precipitated rhabdomyolysis.

Rhinocerebral mucormycosis associated with diabetic ketoacidosis.

Rhinocerebral mucormycosis with hemiparesis occurred in a young woman who was not a known diabetic. Rhyzopus species grew from the initial nasal biopsy. The patient was treated with amphotericin B, in addition to control of diabetic ketoacidosis. Surgical intervention was not done. The patient died on the fourth day of hospitalisation.

Boerhaaves' syndrome.

A 47 year old male with Boerhaaves' syndrome is described. A brief review of the literature is also presented.

Determination of scandium in wolframite and in the residues obtained after the extraction of tungsten.

The separation of scandium from iron and manganese by extraction with TBP from hydrochloric acid was studied in detail and this method was applied to the estimation of scandium in wolframite and its residues. The method consists of the extraction of tungsten from the wolframite with sodium carbonate, dissolution of the residue in hydrochloric acid and preferential extraction of iron and scandium from hydrochloric acid, stripping of the scandium with 8 M hydrochloric acid and re-extraction of accompanying iron with fresh TBP, precipitation of scandium with ammonia in presence of ammonium chloride, and final purification of the scandium by TBP extraction.