Synchronous pancreatic and scrotal tuberculosis: Double jeopardy.

We describe a patient who presented with scrotal swelling followed by non-healing and discharging scrotal sinuses, following local trauma and was initially suspected to have an infected scrotal hematoma. An evaluation revealed it to be scrotal tuberculosis. He also complained of upper abdominal pain and on transabdominal ultrasonography was detected to have a mass in the head of the pancreas. Evaluation of the pancreatic mass revealed it to be pancreatic tuberculosis. Both lesions responded well to anti-tubercular therapy. This is an unusual case of two rare sites of extrapulmonary tuberculosis presenting simultaneously in the same individual. Care needs to be exercised while evaluating any non-healing ulcers or sinuses and mass lesions in countries endemic for tuberculosis as this disease can be a great masquerader.

Prevalence of gastro-esophageal reflux disease in patients with difficult to control asthma and effect of proton pump inhibitor therapy on asthma symptoms, reflux symptoms, pulmonary function and requirement for asthma medications.

BACKGROUND: The hypothesis that GER can trigger or exacerbate asthma is supported by several clinical trials that have shown amelioration in asthma symptoms and/or an improvement in pulmonary function after antireflux therapy. AIMS: To investigate the prevalence of GER in patients with difficult to control asthma and to determine the effect of omeprazole on asthma symptoms, reflux symptoms, pulmonary function and on the requirement of asthma medications. MATERIALS AND METHODS: Patients with difficult to control asthma were recruited into the study. All patients underwent esophageal manometry and 24 hour esophageal pH monitoring. Pulmonary function tests were done before and after treatment. The severity of asthma and reflux was assessed by a 1 week pulmonary symptom score(PSS) and reflux symptom score(RSS) respectively before and after treatment. Those who had an abnormal pH study (pH <4 in the distal esophagus for >5% of the time) underwent anti-GER treatment with lifestyle changes, and a proton pump inhibitor (omeprazole 40 mg, bid) for 3 months. Asthma medications were added or deleted based on severity of asthma. RESULTS: Out of 250 asthmatic patients screened, forty patients fulfilled the inclusion criteria. Twenty eight of 40 patients(70%) were diagnosed to have GERD. Of the patients 28 with GER, 8 patients(28.5%) had no reflux symptoms. On 24 hr pH metry, the percentage time pH <4.0 was 10.81 ± 4.72 and 1.11 ± 1.21; Deemester score was 37.65 ± 14.54 and 4.89 ± 6.39 (p-value is 0.0001) in GERD and non-GERD patients respectively.In GERD group, post treatment reflux symptom score(RSS) improved from 22.39 ± 14.99 to 1.04 ± 1.07, pulmonary symptom score(PSS) improved from 27.14 ± 7.49 to 13.82 ± 4.21 and night time asthma symptom score(NASS) improved from 6.71 ± 1.80 to 3.04 ± 1.23 (p-value <0.0001). After treatment, FEV1 and PEFR increased from 1.38 ± 0.57 and 4.14 ± 1.97 to 1.47 ± 0.54 and 5.56 ± 1.72, respectively (p-value 0.00114). CONCLUSIONS: PPI therapy improves nocturnal asthma symptoms, daytime asthma symptoms, pulmonary function and decreases requirement of asthma medications in these patients.

Atypical histological features of ulcerative colitis.

INTRODUCTION: The diagnosis of ulcerative colitis is based on combination of clinical, endoscopic and pathological findings. However cases have been reported showing atypical endoscopic and histological features in ulcerative colitis. Hence the objective of this study was to determine the atypical features of new onset ulcerative colitis in adult population. METHODS: A total 110 newly diagnosed cases of ulcerative colitis were enrolled in the study over a period of five years. The diagnosis of ulcerative colitis was made by correlating clinical, endoscopic and histological features. Biopsies from representative areas were processed routinely. Endoscopic and histological evaluation was carried out for atypical features. RESULTS: Majority of the patients (75.4%) were between 21-50 years of age with male to female ratio of 2.2:1. A significant number of patients showed atypical endoscopic findings in the form of rectal sparing in 12 (10.9%) and skip lesions in 24 (21.8%) patients. Atypical features noted on histology included normal surface epithelium in 8 (7.3%), predominant polymorphs in 42 (38%), predominant eosinophils in 7 (6.3%), normal crypt architecture in 1 (0.9%) and well preserved goblet cells in 30 (28%) cases. CONCLUSION: A significant number of patients with new onset ulcerative colitis showed atypical pattern of disease endoscopically as well as histologically. Pathologists should be aware of these atypical findings in cases of ulcerative colitis so as to avoid misdiagnosis.

Prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is commonly associated with type 2 diabetes mellitus (DM) though its prevalence is not well studied. We conducted a prospective study of prevalence and risk factors of NAFLD in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: 204 type 2 DM patients attending an out-patient diabetic clinic underwent abdominal sonography. Ninty of 127 patients with fatty infiltration on ultrasound consented for liver biopsy, clinical and biochemical workup. RESULTS: Eighty seven percent had NAFLD on histology with 62.6% steatohepatitis and 37.3% fibrosis. Age, duration of diabetes mellitus, degree of glycemic control, body mass index, waist circumference, family history of diabetes mellitus, did not predict the presence or severity of NAFLD or fibrosis. Serum alanine aminostranferase (ALT) and alkaline phosphatase levels, though within normal limits, were significantly higher in patients with steatohepatitis. Prevalence of NASH increased with increase in the components of the metabolic syndrome. Serum AST/ALT ratio were also significantly higher (p-0.049) in patients with severe fibrosis. All patients with severe fibrosis had metabolic syndrome. CONCLUSIONS: Prevalence of NAFLD and NASH in our cohort of type 2 DM patients is high and increases with multiple components of metabolic syndrome. NASH and advanced fibrosis can occur in diabetic patients without any symptoms, signs or routine laboratory test abnormalities.

Hepatitis B subtypes and hepatitis C genotypes in cirrhosis in western India: results of a pilot study.

BACKGROUND: Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the major causes of viral chronic liver diseases in India. HBV subtypes and HCV genotypes have not been reported from Western India. The aims of the study were (i) To study the prevalence of viral markers to HBV and HCV in adult cirrhotics, (ii) To determine HBV subtypes and HCV genotypes using serological and molecular biological methods. METHODS: A total of 99 adult cirrhotic patients, proven by liver biopsy, laparoscopy, or a combined score of clinical features, biochemical tests, ultrasonography of abdomen, and radioisotope 99m Technetium scan in presence of oesophageal varices were studied. Sera collected from these patients were stored at -8 degrees C and subjected to various tests. HBsAg was determined by ELISA, anti-HBc by ELISA and anti HCV Ab was determined by the third generation ELISA. HBsAg subtypes were determined by enzyme immunoassay. HCV RNA was determined by PCR in those who tested positive for anti HCV antibody. Genotyping of HCV was done with a second generation PCR. RESULTS: HBsAg was detected in 16, out of which subtyping was possible in 14, adw was found in 6 and ayw in 8. Anti HCV Ab was found in 5. Genotyping was possible in three samples which revealed one to be of genotypes 3, one of genetic group 4, and one of genetic group 5. CONCLUSIONS: Subtypes and genotypes of HBV and HCV have not been reported from Western India. Their determination can have implications in understanding the spectrum of disease, characteristics and response to treatment.

Spectrum of liver diseases in HIV infection.

BACKGROUND: Most earlier reports on the spectrum of liver diseases in HIV-infected individuals originated from the West. OBJECTIVE: To study the spectrum of liver diseases in HIV-infected individuals. METHODS: Seventy four consecutive HIV-positive patients (57 men; age range 23-75 years, mean 34) were studied prospectively with clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, markers of hepatitis B (HBV) and C (HCV) viruses, and liver histology whenever necessary. RESULTS: Thirty four patients (45%) were chronic alcoholics. Mean (SD) absolute lymphocyte count was 2521 (1271)/mm3; count < 2000/ mm3 was present in 20 patients. Serum bilirubin, transaminases and alkaline phosphatase levels were elevated in 13%, 13% and 24% of patients, respectively. Ultrasonography detected an abscess in two patients (tuberculous-1, amebic-1). Evidence of exposure to HBV was present in 81% (HBsAg-12, hepatitis B core and/or surface antibody-48); anti-HCV antibody was positive in 29.7%. Five patients with liver tuberculosis (granuloma-4, abscess-1) had AFB either in liver tissue or lymph nodes. CONCLUSION: Chronic alcoholism, HBV and HCV infection, hepatic tuberculosis, and evidence of other liver disease were common in patients with HIV infection.

PIP: A prospective study of 74 consecutive HIV patients (mean age, 34 years) at a public hospital in Mumbai, India, found evidence of hepatitis B and C virus, hepatic tuberculosis, and other liver disease. Clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, hepatitis B and C virus markers, and liver histology were performed. 34 patients (45%) were classified as chronic alcoholics on the basis of a history of consumption of at least 80 g of alcohol daily for at least 5 years and test findings. 59 (80%) had a history of multiple sex partners or encounters with commercial sex workers. 12 patients (16%) were hepatitis B surface antigen-positive and 22 (30%) were positive for hepatitis C virus antibody. Bilirubin, transaminases, and alkaline phosphatase were elevated in 13%, 13%, and 24%, respectively. Liver cirrhosis was present in 5 patients. Hepatitis B virus was detected in 4 patients and dual hepatitis B and C infection was found in another patient. Finally, 5 patients had liver tuberculosis. The mean absolute lymphocyte count was 2521/cu. mm; only 20 had a count indicative of immunosuppression (2000/cu. mm). These findings confirm that hepatic effects are a major feature of HIV infection in India.

Impact of human immunodeficiency virus infection on abdominal tuberculosis in western India.

We studied the seroprevalence of human immunodeficiency virus infection in patients with pulmonary tuberculosis and abdominal tuberculosis. We also assessed the clinical characteristics, risk factors, tuberculin status, site, and response to therapy of abdominal tuberculosis in human immunodeficiency virus (HIV)-seropositive and HIV-seronegative patients. Volunteer blood donors (n = 8,395), patients with pulmonary tuberculosis (n = 387), and patients with abdominal tuberculosis (n = 108) were screened for HIV 1 and/or HIV 2 by enzyme-linked immunosorbent assay (ELISA; Torrent, India) and positivity reconfirmed by a repeat ELISA and Western blot test. The HIV seroprevalence in the abdominal tuberculosis patients (16.6%) was significantly higher compared with those with pulmonary tuberculosis (6.9%, p < 0.05) and volunteer blood donors (1.4%, p < 0.01). Absolute lymphocyte counts did not differ between the HIV-seropositive and HIV-seronegative patients (2,044.94 +/- 830 vs 2,261.34 +/- 805/mm3, p = NS). The Mantoux reaction was larger in the HIV-seronegative group as compared with the HIV-seropositive group (14.8 mm vs. 9.5 mm, p < 0.05). Tuberculosis patients responded well to conventional antituberculosis drugs in standard doses regardless of their HIV status.

PIP: Human immunodeficiency virus (HIV) infection dramatically increases the risk of progression of latent tuberculosis infection. A case-control study conducted during 1992-95 at an urban teaching hospital in Mumbai, India, investigated the seroprevalence of HIV infection in patients with pulmonary and abdominal tuberculosis. Enrolled were 387 patients with active pulmonary tuberculosis, 108 with abdominal tuberculosis, and 8359 volunteer blood donors. The HIV seroprevalence rates in these 3 groups were 6.9%, 16.6%, and 1.4%, respectively. The majority of HIV-infected abdominal tuberculosis patients were in the early clinical stages of the disease and not significantly immunosuppressed. These patients had higher rates of lymphatic and hepatic tuberculosis than seronegative patients, suggesting disease dissemination. All tuberculosis patients, regardless of HIV status, responded well to antituberculous drugs in standard doses. These findings suggest that all patients with pulmonary and abdominal tuberculosis should be screened for HIV. In addition, long-term chemoprophylaxis in HIV-infected persons from tuberculosis-endemic areas should be considered.

Gallbladder varices: diagnosis in children with portal hypertension on duplex sonography.

We established the prevalence of gallbladder varices (GBVs) as seen on duplex sonogram of children with portal hypertension. Fifty-five consecutive children with portal hypertension underwent duplex sonographic examination by an experienced sonologist who was blinded to clinical presentation. Forty children had extrahepatic portovenous obstruction (EHPVO), 12 had cirrhosis, and three had noncirrhotic portal hypertension. GBVs were seen on sonography in 10 of 40 children with EHPVO (25%), two of 12 children with cirrhosis (16.6%), and no children with noncirrhotic portal hypertension. Sonographic findings of GBVs were confirmed on duplex sonographic imaging. Among patients with EHPVO, GBVs did not correlate with size of esophageal varices, number of sessions of sclerotherapy, presence or absence of gastric varices, portal gastropathy, or splenorenal shunt placement. In cirrhotic patients, GBVs did not correlate with Child Pugh grade. Children with EHPVO have a higher incidence of developing GBVs. The clinical significance of GBVs is their propensity to bleed during biliary surgery; thus, the operating surgeon should be made aware of them.

Achalasia cardia dilatation using polyethylene balloon (Rigiflex) dilators.

OBJECTIVE: Results of 20 dilatation sessions in 15 patients with achalasia cardia were assessed to determine the safety and efficacy of polyethylene balloon achalasia dilators (Rigiflex). METHODS: All patients underwent an initial dilatation by inflating a 30 mm balloon to 9 psi for one minute. Need for subsequent dilatations was assessed on symptom assessment; 35 mm balloon was used for repeat procedure. RESULTS: Overall success rate was 93.3%. The 30 mm balloon achieved a satisfactory result in 73.3% and the 35 mm balloon in 75% of the remainder. Only one patient needed surgery. No short-term complications were observed. The only late complication encountered over an average follow-up period of 16.2 months was gastroesophageal reflux in two patients. CONCLUSIONS: Dilatation using Rigiflex dilators is a safe, effective and simple procedure for treating patients with achalasia.

Asymptomatic spinal tuberculosis presenting as esophageal stricture.

Esophageal tuberculosis is rare and is usually due to secondary extension from contiguous structures. We report a patient who presented with dysphagia and was found to have esophageal stricture. Endoscopic biopsy was not suggestive of malignancy or tuberculosis. CT scan of the thorax revealed involvement of the fourth thoracic vertebra with paratracheal lymphadenopathy. The patient responded to anti-tubercular therapy.