A Rare Case of Brucellosis with Multivalvular Endocarditis and Complete Heart Block.

BACKGROUND: Brucellosis is a public health concern that affects multiple organs. However, cardiovascular problems arise infrequently, affecting fewer than 2% of cases, typically presenting as endocarditis. CASE PRESENTATION: A 50-year male was admitted with low-grade fever, night sweats, weight loss (13 kg), malaise, and generalized weakness for the past 6 months. On clinical examination, he was febrile with 39.0°C, an average heart rate of 54 bpm, and 100/40 mmHg blood pressure. On cardiovascular examination, S1 and S2 were soft with pan systolic murmur present in the mitral area, and the early diastolic murmur was present in the left third intercostal space. Electrocardiography was suggestive of third-degree heart block with AV dissociation. Transthoracic echocardiography showed mobile vegetations attached to multiple valves- an aortic valve (18.2x11.9mm) and a mitral valve (2.9x7.5mm) with perivalvular abscess. He was given oral doxycycline (100mg B.D.) and rifampicin (600mg/day); the patient responded, but the AV block did not resolve. CONCLUSION: This report has drawn attention to multivalvular involvement and cardiac rhythm abnormalities in Brucellosis (in this case, A.V. dissociation was present) because early diagnosis and treatment can cause a significant decrease in morbidity as well as mortality by appropriate treatment.

Increased concentration of serum gamma-glutamyl transferase in ischemic stroke patients.

BACKGROUND: Stroke is responsible for the largest proportion of neurological disorders causing a significant morbidity. Gamma-glutamyl transferase (GGT) enzyme has an active involvement in atherosclerosis through its role in oxidative and inflammatory mechanisms. Recent evidence suggests that serum GGT is related to the risk and prognosis of cerebrovascular diseases. METHODS: A total of 200 patients (100 with acute ischemic stroke and 100 without stroke) were recruited from various medical wards and medical intensive care unit. Categorical variables were compared between two groups using Chi-squared test and odds ratio (OR). Independent sample t-test was used to see to compare mean GGT level of stroke patients with control. RESULTS: There was no statistical difference with respect to distribution of age groups (χ 2 = 1.25, P = 0.741) and gender (χ 2 = 2.678, P = 0.1018) between cases and controls. Mean age of stroke patients (mean [M] = 61.7, standard deviation [SD] = 13.8) did not differ from controls (M = 62.2, SD = 13.6), P = 0.80. The odds of suffering from diabetes were significantly higher in stroke patients than cases (OR = 2.25, P = 0.005). Independent sample t-test found a significant difference in serum GGT level between cases (M = 57.47, SD = 11.8) and control (M = 41.72, SD = 7.5), P ≤ 0.0001. CONCLUSIONS: Serum GGT was significantly higher in stroke patients than age-sex-matched nonstroke patients. Association remained significant in stroke patients irrespective of age, gender, and other risk factors. Stroke patients with diabetes, hypertension, dyslipidemia, obesity, and smoking had higher level serum GGT level than those without these risk factors. Prospective cohort studies can further explore the potential of GGT as a predictor of acute ischemic stroke.

Changes in Hematological Parameters by Quantifying HRCT Chest Results in Patients With COVID-19 in Tertiary Care Hospital.

AIM: To find changes in hematologic parameters in patients who are COVID-19-positive with respect to high resolution computed tomography (HRCT) chest scan so that the exact picture of the disease course can be identified and an adequate treatment protocol can be planned to combat the COVID-19 pandemic. METHODS: Patients' health-related data including age, gender, symptomatology, associated co-morbidities, laboratory test results and HRCT results were collected. RESULTS: The radiologic findings showed ground glass opacities (GGOs) was the most common manifestation. Analysis of HRCTs of patients with COVID-19 showed that lesions were mainly confined to the right and left lower lobes, suggesting that the COVID-19 virus is mainly harbored in the basal areas of the lungs. CONCLUSION: Radiologic and laboratory investigations can greatly help in early detection of COVID-19, thus allowing for timely interventions.

Efficacy of transcutaneous bilirubinometry as compared to serum bilirubin in preterm newborn during phototherapy.

Transcutaneous measurement of bilirubin is being used for neonatal jaundice. Its utility during phototherapy in preterm babies is not established. The objective of our study was to assess the efficacy of transcutaneous bilirubin (TcB) measurement in comparison to total serum bilirubin in preterm newborns at admission and during phototherapy at the covered skin area (glabella). It was a prospective observational study and conducted at the neonatal intensive care unit of a tertiary care hospital from January 2017 to January 2019. One hundred eligible preterm neonates were enrolled. Babies who were very sick, with poor peripheral circulation, edematous, having conjugated hyperbilirubinemia, with major congenital malformations, already received phototherapy or exchange transfusion were excluded. Paired total serum bilirubin and transcutaneous bilirubin were measured at admission and 6 h and 24 h during phototherapy. TcB was measured from the area (glabella) covered by an eye protector during phototherapy. The sample for TsB was taken within 10 min of TcB measurement. The mean differences between TsB and TcB values at admission and 6 h and 24 h of phototherapy were - 0.005 (0.353) mg/dl, - 0.350 (0.611) mg/dl, and - 0.592 (0.353) mg/dl, respectively. At admission or before starting of phototherapy, the difference (TsB-TcB) was statistically not significant (p = .125), while the difference in these values was statistically significant at 6 h and 24 h of phototherapy.Conclusion: TcB measurements from the covered skin area in jaundiced preterm infants during phototherapy were not correlated with TsB and cannot be used as an alternate of serum bilirubin testing. What is known • HPLC bilirubin measurement is a gold standard test for bilirubin measurement but impractical for day to day use. Serum total bilirubin is used for clinical testing.. • There is evidence for use of transcutaneous bilirubinometry for assessment of bilirubin in term newborn. What is new • TcB measurements from a covered skin area in jaundiced preterm newborns under phototherapy were not correlated significantly at 6 h and 24 h of phototherapy, but correlated before phototherapy. • TcB cannot be used as an alternate of serum bilirubin testing in preterm infants during phototherapy.

Complete Blood-count-based Inflammatory Score (CBCS) of COVID-19 Patients at Tertiary Care Center.

CONTEXT: Inflammation is a significant factor driving the rise of multiple cases of viral pneumonia, including COVID-19 infection. Peripheral white blood cells (WBCs), the neutrophil (NEU)-to-lymphocyte (LYM) ratio (NLR), the platelet-to-lymphocyte (PLR) ratio, and hemoglobin (Hb) are markers of systematic inflammatory reaction and often predict disease severity. OBJECTIVE: The current study intended to examine the prognostic importance of hemoglobin (Hb), total leukocyte count (TLC), absolute neutrophile count (ANC), absolute lymphocyte count (ALC), NLR, d-NLR [derived NLR = ANC/(WBC-ANC)], absolute platelet count (APC), and PLR, based on complete blood counts (CBCs) for COVID-19 patients. DESIGN: The research team designed a retrospective that was conducted between March 27 and June 5, 2020, after the first COVID-19 case was reported in Ajmer, Rajasthan, India on March 27. SETTING: The study took place at Jawaharlal Nehru (JLN) Medical College in Ajmer, Rajasthan, India. PARTICIPANTS: The study included 364 participants who were all COVID-positive patients who came to the hospital during the study's period, including patients from various age groups and of both genders. OUTCOME MEASURES: Using the results of the CBC, the research team measured: (1) Hb in g/dl, (2) ANC, (3) ALC, and (4) APC. The neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) were calculated from measurements of the levels of the circulating biomarkers, as cells × 103/µl. RESULT: For participants who were severely symptomatic, the mean age was 57.86 ± 8.92. Males were more likely to experience severe symptoms. Participants' Hb values were significantly different between groups, and TLC, ANC, NLR, d-NLR, and PLR were highest in the severely symptomatic group and lowest in the asymptomatic group. NLR was positively associated with a risk of COVID-19 pneumonia, while Hb was negatively associated with development of pneumonia. CONCLUSIONS: Disease severity and age are independent predictors of poor outcomes. The NLR should be used as a routine blood test that can help in the diagnosis of disease severity in COVID-19. NLR is very simple tool that can be used as a fast and low-cost test that is easily available, even in small centers where the facilities for other tests, such as tests of LDH, CRP, and IL-6, and high resolution CT scans aren't available. Thus, NLR can be used as single independent predictor of COVID-19 disease severity.

Duration of Viral Clearance in Children With SARS-CoV-2 Infection in Rajasthan, India.

OBJECTIVE: To study the clinical and laboratory profile and to assess period for viral clearance in COVID 19 children. METHODS: We reviewed hospital records of children (<18 years) admitted from 1 April to 31 May, 2020 at a tertiary-care public hospital and identified those positive for severe acute respiratory syndrome corona virus (SARS-CoV-2) by RT-PCR of respiratory secretions. RESULTS: 81.2% of the 85 children studied were asymptomatic and 3 (8.5%) died. Severe lymphopenia (43.8%), raised C-reactive protein (93.8%), raised erythrocyte sedimentation rate (75%) and high (>500ng/mL) levels of D-dimer (37.5%) were common. Median (IQR) duration of viral shedding was 7 (5-10) days, with range of 2 to 45 days; 96.3% had viral clearance within 14 days. CONCLUSIONS: Majority of children aged <18 years with SARS-CoV-2 infection had viral clearance within 14 days.

Umbilical Cord Blood Culture in Diagnosis of Early Onset Neonatal Sepsis.

OBJECTIVE: To evaluate the use of umbilical cord blood culture (UCBC) as compared to neonatal blood culture (NBC) in the diagnosis of early onset neonatal sepsis (EONS). METHODS: This hospital based prospective observational study was conducted in the Department of Pediatrics and Department of Obstetrics & Gynaecology at a tertiary care centre of North India from 2017 through 2018. A total of 80 newborns with presence of two or more risk factors for sepsis were included in the study. Blood culture samples were collected from the umbilical cord at delivery and from the neonate within 1 h of birth. RESULTS: UCBC was positive in 17 (21.2%) neonates and NBC was positive in 15 (18.7%) neonates. Out of these positive cases, 10 (45.4%) neonates had similar bacteriological profile in both UCBC and NBC which included Burkholderia cepacia, Acinetobacter species, Enterobacter cloacae and Coagulase-negative Staphylococcus. UCBC had a sensitivity of 66.7%, a specificity of 89.2%, a positive predictive value 58.8% and a negative predictive value 92.1% for the diagnosis of EONS in high risk neonates, considering NBC as the gold standard test. CONCLUSIONS: UCBC is a reliable alternative to NBC for early etiological diagnosis of EONS in high risk neonates. Additional blood sampling from the newborn is suggested if there is any clinical sign of sepsis.

Monotherapy of RAAS blockers and mobilization of aldosterone: A mechanistic perspective study in kidney disease.

In patients with acute kidney injury progressively converting into chronic kidney disease (CKD), proteinuria and high blood pressure predict progression to end-stage renal disease (ESRD). Although, Renin-angiotensin-aldosterone system (RAAS) regulates blood pressure and kidney disease through both direct and indirect mechanisms. RAAS blockers that act at the level of angiotensin or lower in the cascade can cause compensatory increases in the plasma renin and angiotensin II level. Here, in this review article, we are exploring the evidence-based on RAAS blockade action releases of aldosterone and hypothesizing the molecular mechanism for converting the acute kidney injury into chronic kidney disease to end-stage renal disease.

Hallervorden-Spatz Syndrome with Seizures.

Hallervorden-Spatz syndrome is a disorder characterized by dystonia, parkinsonism, and iron accumulation in the brain. The disease is caused by mutations in gene encoding pantothenate kinase 2 (PANK2) and patients have pantothenate kinase-associated neurodegeneration. We present an 8-year-old boy with progressive muscle dystonia, neuroregression, frequent fall and multiple injury marks of different stages. Seizures are rare with PANK2. This child had seizure onset at 4 years of age and seizure free on valproate and levetricetam. The CT scan showed tiger eye appearance and mutations on PANK2 gene.

Chanarin Dorfman syndrome: a case report with novel nonsense mutation.

Chanarin Dorfman syndrome (CDS) is a very rare neutral lipid metabolism disorder with multisystem involvement. It is inherited as an autosomal recessive manner. It is characterized with congenital ichthyosiform erythroderma and involvement of liver, muscle, and central nervous system. Demonstration of lipid vacuoles in neutrophils from peripheral blood smears in patients with ichthyosiform erythroderma leads to the diagnosis. We report a novel ABHD5 truncating variant in a twenty nine month old female child, who presented with icthyosiform erythroderma.

Umbilical Cord Milking and Hematological Parameters in Moderate to Late Preterm Neonates: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of umbilical cord milking on hematological parameters at 6 weeks of age in late preterm neonates. DESIGN: Randomized controlled trial. SETTING: A tertiary care center of Northern India during 2013-14. PARTICIPANTS: 200 moderate to late preterm neonates randomly allocated to early cord clamping or umbilical cord milking group (100 in each). INTERVENTION: In milking group, 25 cm length of cord was milked towards the baby thrice after separating (within 30 s) it from placenta. MAIN OUTCOME MEASURES: Hemoglobin and serum ferritin at 6 weeks of age. RESULTS: Mean (SD) serum ferritin [428.9 (217.6) vs. 237.5 (118.6) ng/mL; P< 0.01] and hemoglobin [12.1 (1.5) vs. 10.4 (1.2) gm/dL; P<0.01] at 6 weeks were significantly higher in umbilical cord milking group. In early neonatal period, hemodynamic and hematological parameters were not significantly different. Higher incidence of jaundice with higher phototherapy rates (33% vs. 9%; P<0.01) were noted in umbilical cord milking group. CONCLUSIONS: In preterm neonates, umbilical cord milking at birth enhances iron stores at 6 weeks of age. Higher phototherapy rates with this intervention are a matter of concern.

Comparison of Umbilical Cord Milking and Delayed Cord Clamping on Cerebral Blood Flow in Term Neonates.

OBJECTIVE: To compare the effect of umbilical cord milking (UCM) and delayed cord clamping (DCC) on cerebral blood flow in term neonates. METHODS: This randomized controlled trial was conducted at a teaching hospital in India during 2012 to 2013. Two hundred newborns (>36wk) were randomized to UCM and DCC groups. UCM was done on 25cm of cord length. In DCC group, clamping was delayed by 60 to 90s. Resistive Index (RI), Pulsatility Index (PI) and cerebral blood flow velocities of middle cerebral artery (MCA) were measured at 24 to 48h of life. RESULTS: Baseline characteristics and hemodynamic parameters were comparable. Mean PI [1.18 (0.26)] and RI [0.65 (0.08)] in UCM group was comparable to mean PI [1.18 (0.25)] and RI [0.65 (0.08)] in DCC group. The peak systolic velocity and end diastolic velocity (cm/s) of blood flow in MCA for UCM group were 34.94 (11.82) and 11.71 (4.75) respectively, while in DCC group they were 37.24 (12.63) and 13.07 (4.78) (p 0.23 and 0.07) respectively. Indices among growth retarded babies were not different. CONCLUSIONS: DCC and UCM had similar effect on cerebral blood flow velocities and Doppler indices in MCA, in term neonates.

Comparison of two types of intervention to enhance placental redistribution in term infants: randomized control trial.

The objective of the study was to compare the effect of umbilical cord milking (UCM) and delayed cord clamping (DCC) on hematological parameters (serum ferritin and hemoglobin) at 6 weeks of life in term neonates. It was a randomized controlled trail conducted at a teaching hospital in North India during August 2012 to August 2013. Babies born at >36 weeks of gestation were randomized in two groups, UCM and DCC (100 in each group). Umbilical cord milking was done after cutting and clamping the cord at 25 cm from the umbilicus. In DCC group, clamping was delayed by 60 to 90 s before cutting the cord. The baseline characteristics were comparable in the two groups. Mean serum ferritin (134.0 ng/ml [89.8]) and mean hemoglobin (11.0 gm/dl [2.4]) in umbilical cord milking group was comparable to mean serum ferritin (142.7 ng/ml [87.1]) and hemoglobin (11.3 gm/dl [2.6]) in DCC group at 6 weeks of age. There was no difference in hemodynamic status, cranial Doppler indices, and adverse neonatal outcomes among the two groups. CONCLUSION: In term neonates, the DCC and UCM had comparable effect on hematological parameters at 6 weeks of life. WHAT IS KNOWN: • Delayed cord blood clamping improves certain hematologic parameters for neonates, which is potentially important in populations with high rates of neonatal and childhood anemia, but that delayed cord blood clamping may not be feasible in clinical situations when neonatal resuscitation is urgent. WHAT IS NEW: • There is no significant difference in ferritin and hemoglobin levels at 6 weeks among term, Indian neonates who had UCM and DCC and that this study may give support to the practice of UCM in term deliveries when DCC is not feasible.

Crouzon syndrome with bony upper airway obstruction: case report and review literature.

Crouzon syndrome is a rare genetic disorder. It is inherited as an autosomal dominant pattern. Mutations in the FGFR2 gene are known to cause Crouzon syndrome. Craniofacial abnormalities are common at birth and may progress with time. The severity of these signs and symptoms varies among affected children. A full term, large for date, male baby was delivered to a gravida 2 mother by cesarean section having facial dimorphism suggestive of Crouzon syndrome. Genetic team confirmed the diagnosis. Baby had severe respiratory distress. On work up, upper bony airway narrowing was found (diameter 3 mm). Later on, baby was operated for the same. Baby is asymptomatic now and doing well up to 2 months of follow-up. Management of Crouzon disease is multidisciplinary and early diagnosis has prime importance. Follow-up must ensure late features like hearing problems, vision problems, dental problems, intelligence, cranial synostosis, and upper airway problems.

Prevalence of Rheumatological Manifestations in Diabetic Population from North-West India.

INTRODUCTION: An increased prevalence of rheumatological manifestations is recognised in diabetes and is a common source of disability. The relationship with other risk factors and glycaemic control is uncertain. We designed this study to find out the prevalence of rheumatological manifestations, association with various risk factors and to assess differences between type 1 and type 2 diabetes. MATERIAL AND METHODS: The study was conducted from Jan 2010 to Dec 2011 at tertiary care hospital. We recorded type of diabetes, various risk factors viz age, duration of diabetes, glycaemic control (HbA1C) and BMI and noted prevalence of various rheumatological manifestations by clinical examination, X-ray and if needed CT scan/MRI. We explored correlation between rheumatological manifestations and these variables using logistic regression. RESULTS: The prevalence of rheumatological manifestations was estimated at 570 per 1000 population. The manifestations were more common in type 1 diabetes (62.7%). The various complications observed in the present study were DISH (13%), Frozen Shoulder (20%), Dupuytren's Contracture (7.2%), Osteoarthritis (36.1%), Neuroarthropathy (2.9%), Chieroarthropathy (22.6%) and Flexor Tenosynovitis (8.1%). Among various risk factors, duration of diabetes (odd ratio: 5.127), BMI (odd ratio: 7.429) and age (odd ratio: 4.731) were common risk factors. Poor glycaemic control was also associated with increased prevalence of rheumatological manifestations. CONCLUSION: Rheumatologic manifestations are very common in diabetics and are associated with poor glycaemic control, BMI, duration of diabetes and age of the patients.

Prevalence of micro and macrovascular complications and their risk factors in type-2 diabetes mellitus.

OBJECTIVES: To determine the prevalence of micro and macrovascular complications in type-2 diabetes in Northwest India and its correlation with various risk factors. METHODS: In this study, total 11,157 subjects (M:F 6661:4496), attending the diabetic clinic, were analysed. The study sample resembles the population sample in anthropometric, age and socioeconomic factors. All patients had undergone the test for retinopathy by fundus examination, nephropathy by microalbuminuria, serum creatinine and blood urea, neuropathy by monofilament and biothesiometer, peripheral vascular disease (PVD) by colour doppler and cardiovascular disease by ECG. RESULTS: Among 11,157 subjects, retinopathy was diagnosed in 32.5%, nephropathy was present in 30.2%, peripheral neuropathy was present in 26.8%, coronary heart disease (CHD) was present in 25.8% and peripheral vascular disease (PVD) was present in 28% of the subjects. Multiple logistic regression analyses showed that age had a significant association with retinopathy, neuropathy, coronary heart disease (CHD) and peripheral vascular diseases (PVD). Duration of diabetes had significant association with the neuropathy, nephropathy and PVD. Higher HbA1C increases the risk of retinopathy, neuropathy and nephropathy. Hypertension was associated with nephropathy and coronary heart disease. CONCLUSION: The study highlights the high prevalence of vascular complications in type-2 diabetes in Northwest India. Retinopathy and nephropathy were the commonest complications of diabetes in our study.