Uterine Arteriovenous Malformation: Case Series and Literature Review.

BACKGROUND: Uterine AV malformation is a rare cause of torrential post-abortal hemorrhage, which can present with varying grades of severity. Diagnosis requires a high degree of suspicion and is done with ultrasound and Doppler. CASE SERIES: In our institution, during the period 2008-2013, five cases of symptomatic uterine AVMs have been reported. All of them were in the reproductive age group (22-36 years), presenting with a history of miscarriage or termination of pregnancy for which curettage was done. The presentation was with recurrent bouts of torrential bleeding, some triggered by second curettage, and not controllable with regular measures. Diagnosis was by ultrasound-gray scale, color Doppler, and spectral Doppler. The time interval between the onset of symptoms and the primary curettage was 8-89 days; four patients underwent selective arterial embolization, and one patient opted for hysterectomy. On follow-up, all the four patients are presently free of symptoms; two of them conceived within 2 years of the procedure and carried the pregnancy to term-one resulting in a live-birth and the other intrauterine death. CONCLUSION: Uterine AV malformation should be thought of as a differential diagnosis in all cases presenting with bleeding after miscarriage or curettage, since diagnosis is simple and treatment by selective arterial embolization saves morbidity of surgery and anesthesia, and more importantly reduces hospital stay and the absence from work.

Protein losing enteropathy in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic immunologic disorder that may affect multiple organ systems and present with myriad of clinical features. Gastro-intestinal (GI) manifestations are oral ulcers, dysphagia and abdominal pain caused by autoimmune peritonitis/intestinal vasculitis. Hypoalbuminaemia due to GI loss is uncommon. Protein losing enteropathy (PLE) is a group of clinical entities where there is loss of protein through GI tract. PLE due to SLE is rare but it can be the initial manifestation. Patients usually present with pedal oedema mimicking nephrotic syndrome clinically. It is diagnosed by excluding other causes of hypoalbuminaemia. Radio nucleotide labelled albumin scan is useful in confirming albumin loss through GI tract. Often there is a good response to corticosteroids and immunosuppressive drugs. Here we present two SLE patients whose presenting manifestation was protein losing enteropathy and both improved with corticosteroids.

An uncommon presentation of a rare disease - high-degree AV block with takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is a type of non-ischemic cardiomyopathy in which there is sudden temporary left ventricular dysfunction. High-degree AV block and takotsubo cardiomyopathy have been reported together rarely in medical literature. Here we discuss a case of takotsubo cardiomyopathy presenting with complete heart block. A 72-year-old female presented with retrosternal chest pain. Electrocardiogram showed complete heart block without any significant ST-T changes. Echocardiogram revealed regional wall motion abnormality not consistent with coronary artery disease and was suggestive of apical ballooning. Coronary angiogram showed no significant coronary artery lesion. LV angiogram showed apical ballooning and LV systolic dysfunction. Patient underwent temporary pacemaker implantation. Since the complete heart block did not revert even after 18 days, she underwent a permanent pacemaker implantation.

Atrial flutter and pericarditis--a rare complication of right lobe amoebic liver abscess.

A 38 year old gentleman presented with fever and right hypochondrial pain. On further evaluation he was detected to have an amoebic liver abscess (ALA) in the right lobe of the liver. The abscess yielded anchovy sauce pus on percutaneous drainage. Following the percutaneous drainage the patient developed tachycardia. Electrocardiogram revealed atrial flutter with rapid ventricular rate and ST elevation in all leads suggestive of pericarditis. The atrial flutter was reverted to sinus rhythm by cardioversion. The patient then had an uncomplicated convalescence. Amoebic pericarditis, though rare, is a serious complication of amoebic liver abscess. Pericardial complications are usually seen with left lobe liver abscess due to its proximity. Both pericarditis and cardiac arrhythmias due to amoebic liver abscess especially from right lobe are very rare.

Disseminated infection with Strongyloides stercoralis in a diabetic patient.

A 58-year-old male diabetic who was operated for carcinoma larynx 4 years back was admitted with exertional dyspnoea and bilateral leg swelling for the past 2 years. Over the last 2 months, there was a progressive worsening of symptoms. Echocardiography done 2 years back showed pericardial effusion. Echo done during the current admission also showed pericardial effusion with preserved left ventricular function; cytological examination of the pericardial fluid showed larvae of Strongyloides stercoralis. He was treated with antinematodal drugs. A follow-up echo done at discharge showed no pericardial effusion and the patient was completely asymptomatic. To our knowledge, this is the first reported case of Strongyloides pericardial effusion in a diabetic patient.

Percutaneous recanalization and balloon angioplasty of congenital isolated local atresia of the aortic isthmus in adults.

Congenital isolated local atresia of the aortic isthmus is anatomically similar and morphogenetically related to congenital coarctation of the aorta and was encountered in 4 out of 26 consecutive adult patients selected for coarctation angioplasty at our center. Anterograde recanalization of the atresia was safely and successfully accomplished in all four patients, using a brachial approach. Balloon dilation in the four patients, with ancillary stent implantation in one patient, resulted in reduction of translesion gradient from 84 +/- 11 mm Hg to 9 +/- 7 mm Hg without complications. Angiography in the three non-stented patients after a mean follow-up of 13 months showed no evidence of restenosis, dissection or aneurysm formation, though one patient had mild dilatation of the posterior aspect of the aortic isthmus. The clinical presentation of patients with isolated local aortic atresia, and their short- to mid-term response to percutaneous treatment, is similar to that of patients with isolated severe coarctation of aorta.

Transjugular approach to concurrent mitral-aortic and mitral-tricuspid balloon valvuloplasty.

A transjugular approach was successfully used for concurrent mitral-aortic and mitral-tricuspid valvuloplasty in one patient each. This approach simplifies antegrade transvenous aortic valve dilatation in rheumatic aortic stenosis. Advantages obtained by transjugular tricuspid valvuloplasty are easy crossing of the tricuspid valve and stable balloon position, co-axial with the tricuspid orifice.

Prostate-thyroid axis: stimulatory effects of ventral prostate secretions on thyroid function.

BACKGROUND: Endocrine cells of the prostate secrete thyrotropin (TSH)-releasing hormone (TRH), TRH- and TSH-like peptides, and growth factors. Propylthiouracil- and methimazole-induced hypothyroidism increased prostatic levels of TRH in rats as in hypothalamus, whereas thyroxine (T4) replacement decreased TRH. From these reports, we inferred the existence of a prostate-thyroid axis. METHODS: The influence of the prostate on the thyroid gland was studied in albino rats. Ventral prostate was surgically removed on day 31 postpartum. The animals were sacrificed on day 60 postoperation. Serum thyroid hormones were assayed by radioimmunoassay (RIA). For in vitro studies, normal thyroid and ventral prostate glands were cocultured with or without thyroid-stimulating hormone (TSH) antibody, to assess the direct influence of prostatic secretions on thyroid hormone secretion. RESULTS: Serum total and free T4 and triiodothyronine (T3) were significantly reduced in ventral prostatectomized rats. Histological analysis of the thyroid showed that the diameters of the peripheral and middle follicles, colloid epithelial cells, and nuclei were increased in prostatectomized rats, indicating hypothyroid status. Total T3 and T4 were significantly elevated in the culture medium when thyroid and prostate were cocultured, irrespective of the presence of TSH antibody. CONCLUSIONS: The present study suggests that ventral prostatic secretions have a stimulatory role on the thyroid gland.

Impact of altered thyroid hormone status on prostatic glycosidases.

The impact of hyper- and hypothyroidism on prostatic glycosidases was investigated. Hyper-thyroidism was induced by administering L-thyroxine (25 micrograms/100 g body weight/day) for 60 days and hypothyroidism was induced by total thyroidectomy. To test the direct influence of thyroid hormones, prostatic lobes were incubated with different concentrations (10, 25 and 50 ng/mL) of T3 and beta-N-acetylglucosaminidase and beta-N-acetylgalactosaminidase were assayed. Serum levels of thyroid hormones, oestradiol and testosterone increased in hyperthyroid, and decreased in hypothyroid rats. TSH decreased in hyperthyroid, and an opposite trend was seen in thyroidectomized, rats. Prostatic [anterior (coagulating glands), dorsolateral and ventral prostates] beta-glucosidase, beta-galactosidase, beta-N-acetylglucosaminidase and beta-N-acetylgalactosaminidase activities increased uniformly in hyperthyroid, and decreased in thyroidectomized, rats. In vitro studies showed a dose-dependent stimulatory effect of T3 on beta-N-acetylglucosaminidase and beta-N-acetylgalactosaminidase in all three lobes of the prostate. From the present study, it is concluded that hyperthyroidism augments and hypothyroidism inhibits prostatic glycosidases and T3 has a direct stimulatory effect on these enzymes.

Rheumatic fever chemoprophylaxis in adults.

In 2340 adult patients above the age of 26 years with rheumatic valvular disease (RHD) seen since 1987, injection benzathine penicillin (once in 3 weeks) was discontinued and the patients were followed for evidence of rheumatic fever for a period of one to nine years (mean of 3 years). Recurrence of rheumatic fever was seen in 5 patients (0.21%). This study confirms that recurrence of rheumatic fever in patients with RHD above 26 years of age is very low and hence we recommend long term chemoprophylaxis to the patients above the age of 26 on an individual basis.