Acute parkinsonism in a patient with myxedema crisis: A case report.

Both myxedema crisis and Sheehan's syndrome are uncommon conditions. The first-time presentation as myxedema crisis is rare in Sheehan's syndrome. The present study describes the case of a 31-year-old female patient who presented with altered sensorium in the emergency room. The patient was not a known case of hypothyroidism, but had a history of secondary amenorrhea and lactation failure following the birth of a child 11 years prior. Upon evaluation, she was found to have hypothermia, hypotension, the delayed relaxation of deep tendon reflexes, bradycardia and hyponatremia, which led to the suspicion of myxedema crisis. Her thyroid function tests were suggestive of secondary hypothyroidism and her pituitary hormonal profile revealed panhypopituitarism. The patient was managed on the lines of myxedema crisis with oral levothyroxine, hydrocortisone infusion, antibiotics and rewarming. Her clinical and biochemical parameters exhibited an improvement; however, her altered sensorium persisted. A repeat neurological examination revealed cogwheel rigidity with paraparesis, which led to the clinical suspicion of acute parkinsonism. Magnetic resonance imaging of the sella and brain was suggestive of an empty sella and extrapontine myelinolysis, substantiating the diagnosis of Sheehan's syndrome with acute parkinsonism. The patient was commenced on levodopa-carbidopa following which there was an improvement in symptoms. The patient improved over the ensuing 6 months and can now perform all household activities. On the whole, the present study indicates that the early suspicion of myxedema crisis, prompt treatment and the recognition of additional aetiology for persistent altered sensorium can result in a successful outcome for the patient.

Clinical profile of patients with hyponatremia in a tertiary care hospital in the sub-Himalayan region.

INTRODUCTION: Hyponatremia, defined as a serum sodium concentration ([Na+]) <135 mEq/L. It is not a disease but rather a pathophysiologic process indicating disturbed water homeostasis. Hyponatremia should be further classified to provide directions for diagnosis and treatment. It is a heterogeneous disorder. The classifications of hyponatremia are commonly based on tonicity and volume status. The initial differentiation in hypotonic and non-hypotonic hyponatremia is important because management is different. Several studies have been conducted previously to measure the incidence of hyponatremia in medically ill patients. Several studies have demonstrated an increased prevalence of hyponatremia in the presence of co-morbid conditions. We conducted this study to bring out various causes of hyponatremia; their relation with sex, age and outcome and hyponatremia's classification and incidence in our hospitalised population. MATERIALS AND METHODS: This study was conducted to find out etiology, classification, prevalence and outcome and its relation with age and sex in patients of hyponatremia admitted in our institution. A total number of 106 patients were studied. RESULTS: Hospital-based incidence of hyponatremia was found to be 1.17%. Mean age of patients in study was 62.25 ± 17.7 years. Male to female ratio was 1.25:1. Altered sensorium was the most common neurological symptom. Ninety-five (90%) patients were hypo-osmolar. Out of ninety four patients, 38 (40%) were euvolemic. Chronic obstructive pulmonary disorder (COPD) with cor pulmonale with right-sided heart failure (n = 9, 31%) was the most common cause in hyper-volemic hyponatremia. Acute gastroenteritis (n = 13, 48%) was the most common cause in hypo-volemic hyponatremia. Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) was the most common cause (n = 20, 53%) of euvolemic hyponatremia. Out of 106 patients, 11 (10.38%) patients expired. CONCLUSION: Hyponatremia acts as a poor prognostic marker of the primary disease. It is important to recognise it early because of the potential morbidity and mortality, economic impact on the patients and health care associated with it. Early management of hyponatremia, which includes determination of the rate of correction, the appropriate interventions and the presence of other underlying disorders, may help in improving the outcome and shortening the hospital stay of the patients.

Guillain Barre syndrome with pulmonary tuberculosis: A case series from a tertiary care hospital.

INTRODUCTION: Guillain-Barre syndrome (GBS) is post-infectious autoimmune polyradiculopathy which characteristically presents with a monophasic illness with CSF albumino-cytological dissociation with partial or complete recovery. The incidence of GBS is about 1 to 2/100,000 per year.[1] Subtypes are described based on electrophysiological patterns, the most common being acute inflammatory demyelinating polyneuropathy (AIDP) and rarer ones being acute motor axonal neuropathy (AMAN), and acute motor and sensory axonal neuropathy (AMSAN). Tuberculosis is prevalent in India with various neurological manifestation including tuberculoma, brain abcess, pott's spine, and radiculomyelopathy.[2] Five cases have been published of tuberculosis and GBS.[34567] The main underlying pathophysiological mechanism is aberrant immune activation due to molecular mimicry against ganglioside in myelin. Although tuberculosis is mainly T-cell-mediated chronic disease, still there are cases reported with tuberculosis with GBS. Here we are going to present four cases of pulmonary tuberculosis presented with GBS. MATERIALS AND METHODS: This study describes clinical profile of four patients who presented with concomitant pulmonary tuberculosis and GBS over a period of 4 years in a tertiary hospital. Diagnosis was made according to Brighton criteria and alternative diagnosis were ruled out by clinical examination, serological markers, and MRI imaging of the spine. All patient underwent thorough investigation including HIV 1, 2, anti-CMV, anti-EBV to rule out other possible triggers of GBS, NCV, CSF study along with sputum AFB culture. ZN staining and CECT thorax were also done to support the diagnosis. RESULTS: Of total four cases, 3 were male and 1 was female who presented with weight loss, anorexia, cough with or without hemoptysis, and acute progressive LMN quadriparesis in which there was typical albumin-cytological dissociation in CSF. Nerve conduction studies were suggestive of AIDP in two patients, AMAN in one patient, and AMSAN in the fourth one. An exhaustive investigation for triggers of GBS were performed for all patients who were treated with IVIG and two of them completely recovered and rest of two did not recover completely after 6 weeks of follow-up. CONCLUSION: In pulmonary tuberculosis, patients with polyneuropathy demands urgent search for GBS as there has been case reports in literature though the association between tuberculosis and GBS is not clear.

Hypertension as Determinant of Hyperuricemia: A Case Control Study from the Sub-Himalayan Region in North India.

Background: Association between hyperuricemia and hypertension has been recognized for many years. Whether hyperuricemia is the cause or the effect is debatable. Materials and methods: This case control study was conducted to assess serum uric acid (SUA) levels in fifty newly diagnosed essential hypertensive patients and fifty normotensive controls which were matched for age and sex. Detailed anthropometric characteristics including height, weight, body mass index and waist hip ratio were measured. Hypertension was classified according to Joint National Committee (JNC) 7 criteria. Hyperuricemia was defined as SUA level of 6.8mg/dl or more in both men and women. SUA was measured by uricase method. Before collecting the blood samples, patients were advised to proceed on overnight fast of minimum eight hrs. Student's t­test for mean of continuous variables and Chi­square test for proportions were used for statistical significance. Results: Present study included 50 newly diagnosed cases of essential hypertension and 50 age and sex matched normotensive healthy volunteer. Prevalence of hyperuricemia was 24% among the cases and 6% among the controls (P < 0 .05). Odds ratio was 4.9 (Cl=1.3 to 18.8). The mean SUA was significantly higher in the cases (5.5±1.7 mg/dl) than in the controls (4.9±1.1 mg/dl; P< 0.05). Odds ratio in male hyperuricemic hypertensive versus hyperuricemic normotensive was 6(CI=1.0 to 33.2) and 4.46(CI=0.4 to 42.5) among female hyperuricemic hypertensive versus hyperuricemic normotensives. Conclusion: Strong positive association was observed between hypertension and hyperuricemia in both male and female patients in this study.

Prevalence of Diabetes Mellitus and Its Risk Factors among Permanently Settled Tribal Individuals in Tribal and Urban Areas in Northern State of Sub-Himalayan Region of India.

Background. Effect of urban environment on the development of DM and its risk factors is studied with an ecological fallacy due to their study designs that formulate the background for the present study. Objective. To study the prevalence of DM and associated lifestyle related risk factors in traditional tribal individuals residing in tribal area and migrating persons of the same tribe to urban area of sub-Himalayan northern state of India. Methodology. Population based cross-sectional study. Results. A total of 8000 individuals (tribal: 4000; urban: 4000) were recruited. Overall, among urban tribes the prevalence of central obesity (59.0%), overweight (29.3%), stage 1 (22.8%) and stage 2 (5.3%) hypertension, and DM (fasting: 7.8%; OGTT: 8.5%) (P = 0.00) was significantly higher than the tribes of tribal area. Based on OGTT, the prevalence of DM was found to be 9.2% among central obese tribes of urban area and 6.7% of tribal area (P = 0.00). DM showed a significant high prevalence among urban tribes with prehypertension (urban: 8.3%; tribal: 2.9%; P = 0.00), and stage 1 (urban: 14.1%; tribal: 8.7%; P = 0.00) and stage 2 (urban: 17.5%; tribal: 13.9%; P = 0.59) hypertension. Conclusion. Urban environment showed a changing lifestyle and high prevalence of DM among tribal migrating urban tribes as compared to traditional tribes.