Risk factors and clinical presentation of rhino-orbital mucormycosis: Lesson learnt during Covid pandemic.

Aim: To analyze the potential predisposing factors and clinical presentation of mucormycosis in patients with COVID-19. Material and Methods: Medical records of 141 patients with COVID-19-associated mucormycosis (CAM) treated at a tertiary care center in Bihar were reviewed. The predisposing factors, clinical features, and imaging findings of mucormycosis were analyzed. Results: The median age was 48 years (IQR, 43-60). A total of 58 patients developed concurrent CAM and 83 post-CAM. The median interval between COVID-19 and onset of CAM symptoms was 15 days (IQR, 9-16). A total of 80 patients received at-home treatment for COVID-19, and 73 had mild-to-moderate disease. While 61 patients received in-hospital treatment, 57 had severe disease. At presentation, 131 patients had hyperglycemia: 64 type 2 diabetes mellitus (DM) and 67 new-onset DM. The history of glucocorticoid use for COVID-19 was present in 125 patients; 47% were administered at home without monitoring plasma glucose. The common presenting features were toothache, periocular or facial pain, and edema. Rhino-orbital mucormycosis was the most common. Imaging revealed rhinosinusitis in all patients, including pansinusitis (68%), pterygopalatine fossa involvement (21%), cavernous sinus thrombosis (38%), brain abscess (8%), and infarct (4%). All patients received intravenous liposomal amphotericin B, and surgical debridement was performed in 113. Conclusion: COVID-19 patients with hyperglycemia are at risk of developing CAM, irrespective of the severity. Timely recognition of symptoms and prompt initiation of therapy by primary healthcare physicians are imperative for enhancing outcomes. Additionally, glucocorticoid overuse should be avoided, and close monitoring for hyperglycemia development is warranted.

Hepatogenous Diabetes as Compared to Type-2 Diabetes Mellitus and Non-diabetes in Patients With Liver Cirrhosis: Magnitude, Characteristics, and Implications.

Aim: Hepatogenous diabetes (HD) is frequently underestimated among cirrhosis patients. The current study assessed the magnitude, clinical characteristics, and implications of HD in cirrhosis patients as compared to the patients with type-2 diabetes mellitus (T2DM) and non-diabetes (ND) cirrhosis. Methods: In a prospective observational study, 338 consecutive eligible cirrhosis patients were screened for diabetes mellitus. A 2-hour oral glucose tolerance test (OGTT) was used to detect HD. The clinical characteristics, complications, and outcomes were ascertained and compared amongst HD, T2DM, and ND patients. Results: In the final study cohort of 316 patients, the proportion of HD, T2DM, and ND was 22.5% (n = 71), 26.3% (n = 83), and 51.3% (n = 162), respectively. HD was the predominant form of diabetes (68.9%) in Child-Pugh class-C cirrhosis. The majority (73%) of HD patients had abnormal OGTT without fasting hyperglycaemia. A lower cut-off of 98.5 mg/dl for fasting blood glucose had a modest sensitivity (72%) and specificity (75%) for predicting HD. In comparison to T2DM patients, HD patients were younger, leaner, and had more advanced cirrhosis. In comparison to ND patients, HD patients were leaner but had higher glycemic indices, serum cholesterol, and arterial ammonia levels. During a median follow-up period of 12 (03-21) months, the frequency of hepatic encephalopathy and variceal haemorrhage were higher in HD and T2DM patients compared to that in the ND group. Conclusions: HD is prevalent in about one fifth of cirrhosis patients. It differs from T2DM and ND in a number of ways, and has association with complications of cirrhosis.

Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report.

For decades, endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the treatment of several biliopancreatic diseases. Although it is a relatively safe procedure, there are certain hazards involved. Hepatic subcapsular hematoma (HSH) is an uncommon complication of ERCP, with only a few cases reported in the literature to date. We present here a case of large HSH that developed 48 hours after an otherwise uneventful ERCP for choledocholithiasis. After being apparently well for the first two days post-ERCP, the patient began to develop abdominal pain and restlessness associated with hemodynamic instability and a decline in hemoglobin levels. Computed tomography (CT) confirmed the presence of a large HSH. The patient was managed nonsurgically with vascular angioembolization followed by ultrasound-guided percutaneous catheter drainage of hematoma. This case highlights the necessity of increasing awareness about this complication in order to aid in early diagnosis and management.

Clinico-epidemiologic characteristics of optic neuritis in a tertiary eye centre in Eastern India based on the status of serum aquaporin-4 antibody.

PURPOSE: To elucidate the clinico-epidemiologic characteristics of optic neuritis based on the status of serum aquaporin-4 antibody (AQP4-Ab) in patients with optic neuritis (ON). METHODS: Medical records of 106 patients with ON and a follow-up of 3 years were reviewed. For each patient, the following data were extracted: medical history, findings of the ocular examination, brain, orbital or spinal MRI, and serological tests for AQP4. The ON was classified as typical or atypical based on disc examination and improvement in vision after intravenous methylprednisolone (IVMP). The clinical findings (typical or atypical), disease course, and outcomes were analyzed according to the serostatus of the ON. RESULTS: 10 patients ((9.4%) were seropositive for AQP4-Ab; all had atypical ON. 96 patients (91%) were seronegative for AQP4-Ab: 36 atypical ON and 60 typical ON. Profound visual impairment at presentation was seen in all patients. However, at the end of the study period, seropositive and seronegative atypical ON had poor visual outcomes as compared to seronegative typical ON (P = 0.002). Five seropositive and four seronegative patients with atypical ON developed transverse myelitis. Bilateral disease with relapse was more in seropositive patients (80%); however, seronegative with atypical ON also had bilateral presentation and relapse in 42% and 41%, respectively. CONCLUSION: AQP4-Ab seropositive patients mostly present with atypical features such as bilateral recurrent ON, poor visual outcome, and increased incidence of transverse myelitis. However, atypical clinical features can also be seen in seronegative ON with a poor visual outcome and a recalcitrant course.

Intestinal Lymphangiectasia Associated With Refractory Ascites in a Cirrhosis Patient.

Lymphatic systems play a very important role in the body fluid homeostasis by interstitial fluid reabsorption. Lymphatic dysfunctions are common in patients with advanced cirrhosis, contributing to ascites and lymphedema. An unusual manifestation of lymphatic dysfunction in patients with cirrhosis is intestinal lymphangiectasia. A sustained rise in lymphatic pressure secondary to portal hypertension often contributes to the rupture of intestinal lymphangiectasia, resulting in the loss of plasma proteins, lymphocytes and lipids via the release of lymph into the intestinal lumen. Therefore, in addition to lymphatic pump failure, lymphangiectasia can lead to further worsening of ascites by causing severe hypoalbuminemia. On endoscopy, lymphangiectasia appears as whitish distended villi in the duodenum. Dietary changes, which include low-fat diet and medium-chain fat, are currently the cornerstone of lymphangiectasia therapy. We report here an interesting case of cirrhosis with recent worsening of ascites associated with severe intestinal lymphangiectasia and splenomesentric venous thrombosis.

Proximal Splenorenal Shunt Surgery for Bleeding Gastric Varices in Non-Cirrhotic Portal Hypertension.

Background The optimal management of gastric variceal bleeding in patients with non-cirrhotic portal hypertension (NCPH) is debatable due to the lack of data from large randomized controlled trials. Here we present our experience on proximal splenorenal shunt (PSRS) surgery in NCPH patients with bleeding gastric varices. Methods Over a five-year period, a total of 25 PSRS surgeries were performed and data was collected prospectively. Nineteen extrahepatic portal vein obstruction (EHPVO) and six non-cirrhotic portal fibrosis (NCPF) patients with bleeding fundic or isolated gastric varices and normal liver function were included. The collected data was analyzed retrospectively. Results Of the 25 patients who underwent PSRS five were lost to follow-up. Twenty patients (80%) were followed up for a median of 3.4 (1-5) years. Gastric variceal regression was noted in all 20 patients with the disappearance of varices in eight patients. On follow-up, shunt thrombosis was noted in four (20%) patients of whom, two had rebleeding between six months and three years after shunt surgery. Conclusion PSRS was effective in controlling gastric variceal hemorrhage in 92% (23 of 25) of patients with preserved liver function.

An Unusual Postoperative Complication of Retrosternal Gastric Pull-Up for Corrosive Esophageal Stricture.

Retrosternal gastric pull-up with side-to-side esophagogastric anastomosis is the surgery done for corrosive esophageal stricture unresponsive to endoscopic dilatation. This surgery is considered safe in terms of morbidity. Complications due to leak from distal esophageal staple line as a result of partially patent bypassed esophageal lumen have never been reported with this surgery. Herein, we report a case in which a leak from distal esophageal staple line resulted in intraabdominal fluid collection, a life-threatening complication. This complication necessitated a second surgery that involved exclusion of the native esophagus at the neck.

Evaluation of factors associated with complications in amoebic liver abscess in a predominantly toddy-drinking population: A retrospective study of 198 cases.

BACKGROUND AND AIM: Although the mortality rate has declined in recent years, amoebic liver abscesses (ALAs) still carry a substantial risk of morbidity. Studies regarding the indicators of severity, complication, or prognosis of ALA are limited in number and heterogeneous in methodology and results. METHODS: Clinicodemographic profile, therapeutic modalities, and outcomes of indoor ALA patients admitted between January 2016 and October 2017 were analyzed. An analysis of possible prognostic factors associated with complications and interventional therapy in patients with ALA was performed retrospectively. RESULTS: Data of 198 patients with ALA (mean age: 45 ± 12.1; M:F ratio: 193:5) were analyzed. The volume of abscess (503.1 ± 391.2: 300.2 ± 305.8 mL), elevated liver enzymes, and duration of hospital stay (11.98 ± 5.75): 10.23 ± 4.1 days) were significantly (P < 0.05) higher in alcoholic, compared to nonalcoholic, individuals. On univariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, and a larger volume of abscess were found to be significantly (P < 0.05) associated with complications. On multivariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, and hyponatremia were found to be significantly (P < 0.05) associated with complications. Male gender, hypoalbuminemia, and larger volume of abscess were significantly (P < 0.05) associated with interventional treatment. CONCLUSION: Older age, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, chronic alcoholism, and smoking are independent factors significantly associated with complications in patients with ALA. Hypoalbuminemia, larger volume of abscess, and male gender are independent variables associated with the requirement of interventional therapy.

Primary encapsulating peritoneal sclerosis in a tuberculosis-endemic region.

Primary encapsulating peritoneal sclerosis is an enigmatic entity that may be erroneously diagnosed as abdominal tuberculosis in tuberculosis-endemic regions. In patients with a history of recurrent intestinal obstruction, a high index of suspicion along with characteristic images of computed tomography scan can help in diagnosis. Unless there is strong supportive evidence preoperatively, empirical antituberculosis treatment should be avoided.

Management of amoebic peritonitis due to ruptured amoebic liver abscess: It's time for a paradigm shift.

Amoebic peritonitis secondary to rupture of amoebic liver abscess (ALA) has been reported to occur in 2.4 to 13% of cases with a high fatality rate. There is still no consensus as to how a ruptured ALA associated with diffuse amoebic peritonitis be optimally managed. The mortality rates following surgical therapy in patients with ruptured ALA freely into the peritoneum have ranged from 20%- to 50%. The introduction of percutaneous catheter drainage (PCD) has opened a new therapeutic possibility for this group of patients and emerging data suggest that PCD should be the preferred option in such group of patients.

Comparative study of intestinal malrotation in infant, children, and adult in a tertiary care center in India.

BACKGROUND: Intestinal malrotation (IM) is an uncommon condition and has varied presentation in different age groups. The study was aimed to evaluate differences in the clinical presentation, diagnosis, treatment, and outcome of IM in infants, children, and adults. METHODS: Data were collected from records of 79 patients with IM. Based on the age of presentation, these patients were categorized into three age groups: infants (up to 1 year), children (1-18 years), and adults (> 18 years). Follow up data were analyzed during 8 to 16 year after corrective surgery. RESULTS: The overall age of presentation ranged from 8 days to 60 years. Twenty-eight, 29, and 22 patients belonged to the infant, children, and adult groups, respectively. The classical presentation of IM (bilious vomiting) was significantly higher in the infant compared to the children and adult groups (100% vs. 62% vs. 9.8%; p < 0.001). All infants presented with acute symptoms. However, children and adults had subacute or chronic presentations, respectively. The incidence of volvulus was significantly higher in the infant group than other two groups, (100% vs. 41% vs. 10%; p < 0.001). Doppler ultrasound was highly accurate in infants (100%), whereas contrast-enhanced computed tomography (CECT) abdomen was found to be most useful in adults. Postoperative complications were more common in adults. CONCLUSION: Intestinal malrotation can present in patients of any age group. An increased awareness about the atypical presentations of this condition among adults may reduce the time to accurate diagnosis of this disease.

Torsion in wandering spleen: CT demonstration of whirl sign.

Wandering spleen is a rare occurrence. Torsion of the splenic pedicle is the major life-threatening complication of this entity. Preoperative diagnosis is based on radiological investigation. We report two consecutive cases, one adult and one child, in whom torsion in a wandering spleen was diagnosed based on a typical whirled appearance of the splenic vessels on computed tomography. We present a review of computed tomographic appearance of splenic torsion, and emphasize the "whirled appearance" as a specific sign for splenic torsion in wandering spleen.

Diagnosis and management of choledochal cysts.

Choledochal cysts are rare disease and of unknown etiology. These are typically a surgical problem of infancy and childhood, but in nearly 20 % of the patients the diagnosis is delayed until adulthood. The presentation and therapeutic strategies for choledochal cysts in adult may differ from that of childhood. The surgical management of choledochal cysts in adults is complicated by associated hepatobiliary pathology. Despite the absence of clinical trials, a consensus for the management of choledochal cysts is excision. This review examines the spectrum of hepatobiliary pathology encountered with choledochal cysts and the surgical alternatives for managing choledochal cysts based on review of relevant literature in English language indexed on MEDLINE.

A giant type IVA choledochal cyst.

Choledochal cysts are uncommon congenital anomalies of the biliary tree. We report a 25-year-old female who presented with palpable abdominal lump, jaundice and fever. She was diagnosed with a huge, type IVA choledochal cyst with enormous asymmetric cystic dilatation of extrahepatic segment of left hepatic duct with the help of ultrasound and magnetic resonance cholangiopancreatography (MRCP). The patient experienced complete recovery after total resection of the entire extrahepatic cyst and Roux-en-Y hepaticojejunostomy at the level of the hilum. We discuss the clinical features, imaging characteristics and treatment of this giant Todani's type IVA choledochal cyst.

Diagnosis and management of choledochal cysts.

Choledochal cysts are rare disease and of unknown etiology. They are typically a surgical problem of infancy and childhood, but in nearly 20% of the patients the diagnosis is delayed until adulthood. The presentation and therapeutic strategies for choledochal cysts in adult may differ from that of childhood. The surgical management of choledochal cysts in adults is complicated by associated hepatobiliary pathology. Despite the absence of clinical trials, a consensus for the management of choledochal cysts is excision. This review examines the spectrum of hepatobiliary pathology encountered with choledochal cysts and the surgical alternatives for managing choledochal cysts based on review of relevant literature in the English language indexed on MEDLINE.