Functional Outcome following Phrenic Nerve Transfer in Brachial Plexus Injury.

Background: Brachial plexus injuries are debilitating injuries resulting in paralyzed shoulder to global paralysis of the upper extremity. Treatment strategies have evolved over the years with nerve transfer forming the mainstay of surgical management. Phrenic nerve provides certain advantages as donor over other options but has been less preferred due to fear of pulmonary complications. In this study, we assess the functional outcomes of phrenic nerve transfer in brachial plexus injuries. Materials and Methods: A retrospective study was performed on 18 patients operated between 2012 and 2017. The mean duration of injury to surgery was 4.56 months and mean follow-up was for 3.66 years. Phrenic nerve was used as donor to neurotize either biceps and brachialis branch of musculocutaneous nerve or suprascapular nerve. Assessment was done through Waikakul score for elbow flexion and Medical Research Council grading for shoulder abduction. Respiratory function assessment was done through questionnaire. Results: Twelve (80%) patients recovered grade 3 and above elbow flexion with 6 patients having a positive endurance test according to Waikakul and a "very good" result. In phrenic to suprascapular transfer group (3 patients), all patients had more than grade 3 recovery of shoulder abduction. No patient complained of respiratory problems. Conclusion: Phrenic nerve can be used as a reliable donor with suitable patient selection with good results in regaining muscle power without any anticipated effects on respiratory function.

Clinical characteristics of patients with diffuse alveolar hemorrhage diagnosed by cytological examination of 1000 bronchoalveolar lavage samples.

BACKGROUND AND AIM: Diffuse alveolar hemorrhage (DAH) is a life-threatening condition due to the extravasation of blood in the alveoli, resulting in hypoxemia and even acute respiratory distress syndrome. This study aimed to describe the clinico-radio-pathological profile of patients diagnosed with DAH and classify it into immune and nonimmune DAH. METHODS: This was a retrospective analytical study. Of a total of 1000 cases of bronchoalveolar lavage fluids (BALF) received for cytological examination, patients fulfilling the clinical, radiological, and laboratory details of cases satisfying the clinical and cytological criteria of DAH (n=47) were studied. RESULTS: The most common cause of immune DAH was ANCA-associated vasculitis (n=13, 27.6%), and that of nonimmune DAH was infections (n=10, 21.3%). Twenty-nine patients (61.7%) had hemoptysis. The most common radiological finding was ground-glass opacities (n=33, 70.2%). In univariate analysis, female sex, mean hemoglobin at admission, total leucocyte count (TLC), platelet count, and erythrocyte sedimentation rate (ESR) were significantly associated with immune-DAH. However, in multivariate analysis, female sex, higher TLC, high platelets, and high ESR were significantly associated with immune DAH. Patients were treated with corticosteroids (n=25, 46.3%), intravenous cyclophosphamide (n=12, 22.2%), plasma exchange (n=7, 13.0%), intravenous immunoglobulin (n=5, 9.3%) and rituximab (n=5, 9.3%). The overall mortality was 8.5% (n=4). CONCLUSIONS: DAH is a life-threatening syndrome that may be classified into immune and nonimmune DAH. Immune-DAH requires aggressive management, whereas nonimmune DAH cases respond best to conservative management.

Late presentation of lane-hamilton syndrome in a 33 year old female: A case report.

Lane-Hamilton syndrome (LHS) is a rare syndromic association between idiopathic pulmonary hemosiderosis and celiac disease (CD). It is usually seen in children below 15 years of age. It can occasionally be seen in adults. We present the case of a 33-year-old female patient who presented with recurrent episodes of hemoptysis to the pulmonary outpatient department. She also gave a history of having frequent loose stools. She was admitted and investigated thoroughly and was found to be suffering from LHS which is a rare disease. High-resolution computed tomography (HRCT) of the chest and duodenal biopsy helped in concluding the diagnosis. She was started on gluten-free diet (GFD) and has responded well with no episodes of hemoptysis on 9-month follow-up and is in good general condition. This case highlights the importance of keeping a high index of suspicion of LHS in a young patient presenting with unexplained hemoptysis and diarrhea. In a known case of CD presenting with hemoptysis, a HRCT chest aids in the diagnosis of LHS. A GFD is the mainstay of long-term treatment, and adherence to this diet shows remarkable improvement in the symptoms of the patient and their overall general condition.

Blocked Filter of Anti-Embolic Device During Carotid Artery Stenting: A Rare Occurrence Posing Challenging Diagnostic Dilemma.

The use of anti-embolic devices (AED's) is a common practice in carotid artery stenting (CAS). It prevents the passage of blood clots and thrombi generated during the procedure from embolizing into the intracranial circulation. Disadvantages include the passage of small particles and complications related to advancement, deployment, and recovery of the filters. The filter of the AED can get clogged due to the high load of the emboli generated during CAS causing a slowing of the intracranial blood flow which normalizes once the filter is removed. Here, we are presenting a case of the filter of AED getting blocked due to entrapped thrombi or blood clots and mimicking dissection and, sharing our experiences associated with the event.

Cerebral Venous Sinus Thrombosis Complicating Middle Ear Infections: A Rare Complication in Post-Antibiotic Era.

In the post-antibiotic era, intracranial and extracranial complications of middle ear infections have become rare. Similarly, cerebral venous sinus thrombosis (CVST), a frequent complication of middle ear infections, has become rare now. Here, we present a case of a 27-year-old male who presented with a short history of severe headache and associated episodes of intractable vomiting. There was also a prior history of right ear discharge one year back which responded to medical management. The patient did not improve clinically even after prompt symptomatic management. Contrast-enhanced magnetic resonance imaging (CEMRI) of the head and contrast-enhanced magnetic resonance venogram (CEMRV) were done, which showed right-sided otomastoiditis complicated with CVST and meningitis. Although the clinical signs of meningeal irritation and mastoid tenderness were not present on clinical examination. The patient was started on anticoagulant therapy and antibiotics for two weeks following which there was marked clinical improvement.

Intracardiac hydatid cyst located in right ventricular outflow tract: a rare site.

Intracardiac hydatid cyst is relatively uncommon and involvement of right ventricular outflow tract is extremely rare. We report a rare case of intracardiac hydatid cyst involving the right ventricular outflow tract and do a review of literature.

Prevalence of Dengue Serotypes and Its Correlation With the Laboratory Profile at a Tertiary Care Hospital in Northwestern India.

Background and aim Dengue fever is an emerging arboviral public health problem in a large endemic population in the tropical and sub-tropical areas of the world, with varying degrees of clinical presentation. This study was aimed at analyzing the clinical and laboratory dynamics of the four dengue serotypes. Methods This institutional review board (IRB)-approved hospital-based observational study was performed with 100 in-patients with dengue infection above 12 years of age, without co-morbidities or known malignancy, in a tertiary care center in Northern India. Results Out of 100 patients, four had concurrent infection with two serotypes. Dengue virus serotype-2 (DENV 2) was the most common serotype (34%) and had the maximum percentage of cases of severe dengue (20.6%). The mean total leukocyte count did not differ between the serotypes. DENV 4 had a significantly higher mean neutrophil percentage and a significantly lower mean lymphocyte percentage than DENV 1 (p-value 0.001 and 0.02, respectively), with a higher percentage of cases of severe dengue (20% vs 14.3%, non-significant). Thrombocytopenia was present in all serotypes of infection. There was a significant difference in the derangement of liver function in DENV 2, 3, and 4 as compared to DENV 1. Mean serum albumin levels were significantly lower in DENV 3 and 4 infections. Cases with co-infection had a much higher derangement of liver function and lower mean serum albumin than infections with a single serotype. The mean blood urea and creatinine levels were in the normal range for all serotypes. No mortality occurred in our study. Conclusion DENV 2 is the most common serotype with maximum severity at our hospital. DENV 2 and DENV 4 have a high percentage of cases with severe dengue (20.6% and 20%, respectively). The mean lymphocyte percentage was significantly lower while hepatic involvement and hypoalbuminemia were greater in DENV 4. Initial serotyping in patients with dengue can help monitor the epidemiological trends and help estimate the clinical and laboratory trends of the different serotypes of dengue infection. Particular care should be taken in patients with co-infection.

A Case Report on Acute Pancreatitis in a Patient With Coronavirus Disease 2019 (COVID-19) Pneumonia.

With the ongoing coronavirus disease 2019 (COVID-19) pandemic, there has been an explosion of scientific literature on the clinical manifestations and pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Gastrointestinal symptoms occur in 15-20% of COVID-19 patients; however, there have not been many case reports on acute pancreatitis in COVID-19 patients. The expression of ACE-2 ([angiotensin-converting enzyme 2] the host receptor for SARS-CoV-2) is very high in the pancreas, which might be a contributing factor, but the high expression is mainly localized to endocrine pancreas. This case report describes a case of a 25-year-old Indian female with COVID-19 with acute pancreatitis in the absence of any other known risk factors for pancreatitis.

Monogenic Lupus with IgA Nephropathy Caused by Spondyloenchondrodysplasia with Immune Dysregulation.

Monogenic disorders causing systemic lupus erythematosus represent a small subset of cases. Type-1 interferonopathies, like spondyloenchondrodysplasia with immune dysregulation constitute an important functional category of monogenic lupus. Apart from autoimmune disorders, neurological and skeletal abnormalities are additional manifestations observed in this disorder. A young female presented with seizures due to acute hemorrhagic stroke secondary to malignant hypertension. On evaluating the cause for hypertension, there was evidence of glomerulonephritis and multiple autoantibodies positivity including dsDNA. A diagnosis of lupus was made based on clinical and laboratory findings. Kidney biopsy revealed mesangial proliferative glomerulonephritis with predominant IgA deposits favouring IgA nephropathy. Additional features in the form of short stature with vertebral abnormalities and bilateral basal ganglia calcification led to evaluation of Type-1 interferonopathies. Sanger sequencing identified a novel compound heterozygous variants c.550C>T (p.Q184*) in exon 3 and c.740T>G (p.L247R) in exon 4 of ACP5 gene. Parents were found to be carriers of the variants in ACP5 gene. Management included antihypertensive agents and symptomatic therapy. On follow-up, there was complete resolution of glomerulonephritis and normalization of blood pressure. This case report documents the classic phenotype comprising autoimmune, skeletal, and neurological abnormalities in spondyloenchondrodysplasia with immune dysregulation with a novel variant on Sanger sequencing in an Indian patient. This report also highlights the rare coexistence of IgA nephropathy in monogenic lupus.

Evaluation of results of various tendon transfers in high and low radial nerve palsy.

BACKGROUND: Various combinations of tendon transfers are available for radial nerve palsy. However, the choice of which set of transfer to be performed in a patient remains an issue of varied opinions among surgeons. The study attempts to evaluate the results of various tendon transfers for radial nerve palsy quantitatively and subjectively. It also identifies which set of transfer is suitable for particular groups of patients. MATERIALS AND METHODS: The study was conducted between 2005 and 2007. A total of 15 tendon transfers were performed using various combinations and evaluated according to Bincaz's criteria, Kapandji scale and effect of tendon transfers on activities of daily living. RESULTS: 13 patients had excellent to fair outcome according to Bincaz's criteria. 2 patients had poor outcome. There was no hindrance in the activities of daily life in all patients. 93.4% of patients were satisfied with the results. CONCLUSION: Every combination of tendon transfers has its own set of merits and demerits. Selection of donor tendons as per occupational need of patients is utmost important. Patients in our series were satisfied with set of transfers using Pronator teres(PT) for wrist extension, Flexor carpi radialis (FCR) for finger extension and rerouted Palmaris longus (PL) for extension of thumb. Flexor carpi ulnaris (FCU) is important for power grip.

White Epidermoid of the Sylvian Fissure Masquerading as a Dermoid Cyst: An Extremely Rare Occurrence.

We report the case of a 30-year-old female with a Sylvian fissure, white epidermoid which was radiologically looking like a dermoid cyst. The female presented with a headache with no neurological deficits. On radiology, the lesion was in Sylvian fissure, T1 hyperintense, T2 hypointense, and with minimal diffusion restriction medially. Hence a preoperative impression of dermoid cyst was made, a quite uncommon location. Intraoperatively, the classical pearly-white flaky appearance of epidermoid was seen which was confirmed histopathologically. White epidermoids appearing so because of high protein content are a rarity and are more likely to cause aseptic meningitis in the event of intraoperative spillage. Differentiating between a dermoid cyst and white epidermoid preoperatively and radiologically is difficult. Dermoids show diffusion restriction and are usually midline, whereas white epidermoids do not show diffusion restriction and are usually lateral. This is the first report of a white epidermoid in Sylvian fissure to the best of our knowledge.