Picking up an insulinoma - The challenges ahead.

Insulinoma is a rare pancreatic neuroendocrine tumour (PNET) with an incidence rate of 4 per million population, and the most common cause of hypoglycaemia due to endogenous hyperinsulinism. We present the story of a 61-year-old male, who was extensively evaluated at many hospitals for his symptoms of giddiness, uneasiness and recurrent black outs for the last 3 months, his symptoms disappearing with a carbohydrate rich meal or sweets. Random sugar and fasting sugar values noted were low, with elevated insulin and C-peptide levels. Diagnosis of insulinoma was confirmed by a DOTA PET scan involving the tail of the pancreas and then surgically removed. Early detection is crucial for early surgery to allay symptoms. We describe our diagnostic and treatment plan with reference to previously published reports.

Clinical and epidemiological profile of snakebite cases - A study from an industrial teaching hospital at Jamshedpur, Jharkhand, India.

Introduction: India accounts for approximately half of the worldwide snakebite deaths. It is often a neglected public health problem and particularly in Jharkhand region where medical facilities are limited. Epidemiological and clinical profile-related studies are scarce. The present study aims to assess the epidemiological profile and clinical features of snakebites encountered in a tertiary-care teaching hospital at Jamshedpur, Jharkhand, India. Aims and Objective: The aim of this study was to assess the clinical profile, outcome and epidemiological factors of snakebite cases, admitted to a tertiary care hospital in Jamshedpur. Material and Methods: This was a retrospective study from 2014 to 2021 wherein a total of 427 snakebite patients were admitted and had received treatment for snakebite at a tertiary-care teaching hospital at Jamshedpur, Jharkhand. All patients who reported with a history of snakebite were included in this study. The demographic and clinical details of each case were obtained and analysed. Result: A total of 427 snakebite cases were admitted to the hospital during the study period. The victims were predominantly males. Majority of the bite cases encountered were from rural areas and were in the second quarter of the year. The site of the bite was largely on the lower limb and the upper limb had fewer bites. The Glasgow Coma Scale was normal in those who presented early. Acute kidney injury, neutrophilic leucocytosis and deranged liver enzymes were associated with bad prognosis. Timely intervention with anti-snake venom offered good result. Conclusion: We had more male patients (69.55%), belonging to rural areas (67.91%), more bites in lower limbs and more cases in the second quarter of the year. Mortality rate was 0.7%.

Late onset crohns ileitis-A diagnostic dilemma.

Crohn's disease may affect individuals across all age groups. Usually, it tends to start at a young age, hence late onset Crohn's disease may be difficult to diagnose. The incidence of late-onset inflammatory bowel disease in the United States is 4 to 8 per 100,000 per year. The incidence of Crohn's disease is more in the United States and Europe and less in Asia and Africa. This makes it more challenging to suspect Crohn's disease in an elderly individual of Indian origin. It may be confused with Irritable bowel syndrome or Intestinal tuberculosis.

Can Subacute Thyroiditis Be a Cause of Fever of Unknown Origin?

Subacute thyroiditis (SAT) is a self-limiting, painful, non-suppurative thyroid gland inflammation, which usually develops two to eight weeks after viral upper respiratory tract infections, accompanied by pain and fever. The thyroid gland is large, painful, and tender. It presents with fever, myalgia, arthralgia, weakness, and sore throat. A 37-year-old male presented to medical ward with a history of fever for three weeks along with swelling of neck and difficulty in swallowing. The patient had features of hyperthyroidism. High-resolution ultrasonography (HRUSG) and thyroid scan were suggestive of thyroiditis. Later on, on follow-up, the patient developed hypothyroidism. He was managed with antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids, and he responded well to the above treatment. The index patient presented as a case of fever which on workup was found to be secondary to subacute thyroiditis (SAT).

Success rate of Remdesivir, Convalescent Plasma, and Tocilizumab in moderate to severe Covid-19 pneumonia: our experience in a tertiary care center.

INTRODUCTION: After the first case of Covid-19 was identified in Wuhan City, China, the numbers increased rapidly all over the world putting a huge burden on the entire healthcare system. Managing these cases posed a great challenge to the treating clinicians in the absence of targeted therapy. At this juncture, few modalities got approved as EUA (Emergency use under authorization) drugs namely Remdesivir, Convalescent Plasma (CP), and Tocilizumab (TCZ) to treat this deadly disease. AIM: To analyze the success rates of EUA therapies for Covid-19 pneumonia in our hospital. MATERIALS AND METHODS: This was a prospective observational study conducted from April 2020 to October 2020 in the department of Medicine at Tata Main Hospital, Jamshedpur, Jharkhand. All adults with moderate to severe Covid-19 as per the WHO criteria were enrolled in the study with their informed consent. Patients with estimated glomerular filtration rate <30 mL/min, deranged liver function tests, electrocardiographic abnormalities, and deranged hematological parameters were excluded from the study. Thorough clinical evaluation was done in all cases. Routine investigations together with CRP, LDH, serum Ferritin, D Dimer and IL6, Chest X-Ray, and HRCT thorax were done in all cases. ECG was done in all cases and 2D-ECHO in selected ones. Depending on their clinical and radiological criteria, patients were treated with various modalities approved under EUA with close monitoring of clinical, biochemical, and radiological parameters. Presenting symptoms, clinical findings, co-morbidities, laboratory parameters, and radiological assessment were analyzed, and statistical analysis was done. The survival rate and in-hospital mortality was analyzed. OBSERVATIONS AND RESULTS: We had a total of 448 patients who were included in our study, out of which 326 were males and 122 were females with a male to female ratio of 2.7:1. Their age varied between 16 and 91 years with an average age of 51.4 years with a standard deviation (SD) of +/- 6.4 years. About 255 patients (57%) received only Remdesivir (176 males, 79 females), 139 (105 males, 35 females) patients (31%) received Remdesivir along with two units of CP, and 38 (32 males, 6 females) patients received a combination of Remdesivir, CP, and TCZ. All patients in our study tolerated the drugs well. About 5% of cases who received CP had minor transfusion reactions. One patient had TRALI and three patients had TACO, which was managed aggressively. Asymptomatic transaminitis was seen in 36% patients. The survival rate in patients treated with Remdesivir was 78%, those with Remdesivir and CP was 44%, and those with all three was 13%. The mean length of stay was 14.23 days with a SD of 9.06 days in patients treated with TCZ in comparison to other two modalities, which was 13.88 days with a standard variation of +/- 8.71 days in Remdesivir and 13.88 days with a SD of 8.73 days in patients treated with CP that was stastically significant. CONCLUSIONS: Though the success rate of various drugs under EUA varies in different studies from all over the world, the data to support their use are encouraging. We also observed satisfying results in our study specially with the use of Remdesivir. Therefore, EUA agents should be used early to fight against COVID-19 along with the other measures as per the protocol laid by ICMR and MoHFW.

Multi-organ dysfunction following honeybee bite-A rare entity.

Honeybee bites have been known to cause localized allergic reactions and anaphylaxis but systemic toxic reactions leading to multiorgan dysfunction is very rare. Serious complications like acute renal failure, acute myocardial infarction (Kounis syndrome) and even death have been reported as the complication of honeybee bite. Herein, we report a case of multiorgan dysfunction following honeybee bite, which was complicated with acute kidney injury, thrombocytopenia, bradycardia, keratitis, and deranged liver function along with localized allergic reaction and pain.

Persistent cough: An unexpected diagnosis.

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death globally. Esophageal squamous cell carcinoma (ESCC) accounts for 70%-90% of esophageal cancers worldwide, 5% are adenocarcinoma, and 5% represent rare malignancies and metastases from other organs. We present a case where a 54-year-old lady, with multiple readmissions for persistent dry cough and respiratory symptoms, turns out to be an esophageal malignancy. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis, suggestive of a probable esophageal malignancy. An upper gastrointestinal endoscopy showed a circumferential esophageal growth which on biopsy and histopathological examination turned out to be a moderately differentiated squamous cell carcinoma of esophagus.