Thyroid Dysfunction in Patients with and Without Venous Thromboembolism: a Case Control Study.

Recent studies report an association between thyroid dysfunction and venous thromboembolism (VTE). Considering the high prevalence of thyroid diseases in India, identification of thyroid dysfunction as a risk factor for VTE will have implications in management. The aim of study was to determine if thyroid dysfunction could be considered as risk factor for unprovoked VTE. The study was conducted on 102 patients with unprovoked VTE and 102 age and gender matched controls in a tertiary care centre. Clinical profile and thyroid function tests (Free T3, Free T4, TSH) including antibody profile (Anti TPO and Anti TG) were compared between two groups. Thyroid disease was identified in 34 cases and 14 controls (33.1% vs. 13.7%, P = 0.001) Out of 34 cases with thyroid dysfunction, 17 had subclinical hypothyroidism (SCH) while 6 out of 14 controls had SCH. Both thyroid dysfunction and SCH were found to be associated with unprovoked VTE, as compared with controls; [Odds ratio (OR) = 3.14, 95% CI 1.56-6.33, P = 0.001] and (OR = 3.71; 95% CI 1.4-9.9; P = 0.01) respectively. Thyroid dysfunction was significantly higher among patients with unprovoked VTE. Thyroid dysfunction, SCH were associated with unprovoked VTE.

Portal Vein Thrombosis in Patients With Cirrhosis of the Liver: Prevalence and Risk Factors.

INTRODUCTION: Chronic liver disease very often culminates into cirrhosis and its associated complications. One of the serious complications is portal venous thrombosis, which can occur due to a variety of risk factors. One significant factor contributing to portal hypertension is portal vein thrombosis (PVT). In this study, we aimed to investigate the prevalence of PVT among patients with liver cirrhosis in a tertiary hospital and identify the factors associated with this complication. METHODOLOGY: This was a cross-sectional observational study of 93 diagnosed liver cirrhosis patients treated at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in southern India between June 2020 and January 2021. A thorough evaluation of the clinical condition of the patients and associated comorbidities was done. The patients then underwent Doppler ultrasound/CECT/MRI to look for PVT and its extent. The collected data were analyzed using Statistical Product and Service Solutions (SPSS, version 24) (IBM SPSS Statistics for Windows, Armonk, NY). Comparison between two proportions was done using two two-tailed Z-test/Fisher's exact tests. RESULTS: Our study found a PVT prevalence of 17.2% in cirrhotic patients, with a higher prevalence of acute PVT than chronic PVT. Ascitic fluid infection, longer duration of cirrhosis, and increased cirrhosis severity were significantly associated with PVT development. We found no significant associations between PVT and gender, hypertension, smoking, diabetes, or the duration of alcohol intake. CONCLUSION: This study highlights the importance of early screening for PVT using Doppler USG in all patients diagnosed with cirrhosis. Additionally, anticoagulation therapy for acute PVT may be considered in patients without bleeding risks.

Prevalence of Overhydration in Patients on Maintenance Haemodialysis As Determined by Body Composition Monitor and Effects of Attaining Target Dry Weight.

INTRODUCTION: Fluid overload in chronic kidney disease (CKD) is an independent risk factor for all-cause mortality. The volume of ultrafiltrate removed during haemodialysis is usually assessed clinically. Assessment of overhydration by body composition monitor (BCM) using bioimpedance spectroscopy is an objective method. This study was conducted to identify the prevalence of overhydration in CKD patients on maintenance haemodialysis and thereby assess the effects of BCM targeted dry weight attainment. METHODS: All patients included in the study were assessed for one month before enrolment for blood pressure, intradialytic events during each dialysis and BP medications. Overhydration was defined as the ratio of overhydration to extracellular water (OH/ECW) > 1.1. Overhydrated patients were brought to BCM targeted dry weight by increasing ultrafiltrate to 500mL/week more than their routine intradialytic weight gain. The effect of attaining BCM target dry weight on blood pressure and intradialytic events were analysed. RESULTS: Out of 110 patients, overhydration was seen in 30 (27.2%); only 20 had clinically evident overhydration. Body composition monitor guided dry weight was achieved in 28 of the 30 patients after a mean duration of 20 weeks. After achieving the target dry weight, there was a significant reduction in intradialytic hypertension events (2.37 vs 1.82 events per session, p-value 0.01). Surprisingly, there was a reduction in episodes of intradialytic hypotension as well, though this did not reach statistical significance. There was a clinically significant reduction in mean systolic and diastolic blood pressures (mean of 5.7mmHg and 2.8mmHg, respectively). CONCLUSION: The study underlines the importance of BCM-based hydration status assessment and target dry weight attainment in better control of intradialytic events and blood pressure in patients on maintenance haemodialysis.

Streptococcus gallolyticus-related spinal epidural abscess.

Spinal epidural abscess (SEA) is a surgical emergency if it causes paraplegia. Staphylococcus aureus and streptococci are the most common causes. Streptococcus gallolyticus has been reported to cause SEA only on three occasions earlier-all were associated with endocarditis or colonic malignancy. We report an older woman with diabetic ketoacidosis who presented with poorly localised back pain, fever and altered sensorium. Her lumbar puncture revealed frank pus, and MRI showed an SEA. She could not be weaned from mechanical ventilation post-surgical decompression, and she succumbed to ventilator-associated pneumonia. A triad of fever, back pain and neurological deficit should lead one to consider intraspinal suppuration. This report is the first S. gallolyticus-related SEA from India and the first in literature that was not associated with either endocarditis or colonic malignancy.

Scrub Typhus and COVID-19 Coinfection Unmasking Antiphospholipid Antibody Syndrome.

Scrub typhus is an acute febrile disease caused by Orientia tsutsugamushi with a clinical course varying from mild to fatal. Vascular thrombosis is rare in scrub typhus. There is an increased risk of thrombotic events in Coronavirus disease 19 (COVID-19). We report a young diabetic female who presented with pulmonary embolism, followed by deep venous thrombosis (DVT) and was found to have coinfection with scrub typhus and COVID-19 with underlying antiphospholipid antibody syndrome.

Malignant Peripheral Nerve Sheath Tumor Presenting as Horner's Syndrome.

Malignant peripheral nerve sheath tumor (MPNST) is a rare, aggressive sarcomatous tumor that arises from peripheral nerve sheath and shows Schwann cell differentiation. They are commonly seen among cases with existing benign plexiform neurofibromas, prior radiation treatment, and large germline mutations involving the entire neurofibromatosis 1 (NF1) gene. MPNST can have varied presentations; hence diagnosis remains a great challenge. Here we report a rare case of MPNST in an NF1 patient who presented with Horner´s syndrome. A young male reported swelling in the neck, dyspnea on exertion, and dysphagia. Subsequently, he was diagnosed to have a malignant peripheral nerve sheath tumor arising from the mediastinum and compressing the ipsilateral cervical sympathetic plexus causing Horner's syndrome. The patient underwent surgical resection of the mediastinal mass followed by chemotherapy. His symptoms improved significantly following treatment. This case report emphasizes the fact that high suspicion of MPNST is required when NF1 cases present with mass lesions, so that early surgical clearance with chemoradiation may offer a near-complete cure.

Concurrent Presentation of Emphysematous Pyelonephritis, Emphysematous Osteomyelitis, and Psoas Abscesses.

Emphysematous pyelonephritis (EPN) is an uncommon necrotizing infection commonly seen in people with diabetes. Emphysematous osteomyelitis (EOM) is a rare form of pyogenic osteomyelitis characterized by the presence of air in the bones. A combination of both these infections has been reported only thrice in the literature. We present the case of a middle-aged diabetic woman who had both these rare infections along with psoas abscesses, a phenomenon that has been described only once previously. The patient required prolonged hospitalization, surgical debridement and drainage, a double-J stent, and meropenem, and she subsequently achieved full recovery.

Diarrhea and Acute Tubular Necrosis Mimicking Hemolytic Uremic Syndrome in a Man With Immunoglobulin A (IgA) Nephropathy.

Immunoglobulin A (IgA) nephropathy is a heterogeneous disease with variable clinical presentations ranging from asymptomatic hematuria to advanced renal failure. A young male diagnosed with IgA vasculitis (skin, joints, and gastrointestinal) one month ago and placed on oral steroids presented with acute diarrhea, hemolytic anemia, renal failure (non-dialysis requiring), altered sensorium, and thrombocytopenia. The stool was found to be positive for Shiga toxin. He improved with methylprednisolone pulse alone, and renal biopsy showed acute tubular injury.

Abortion and Fulminant Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension (IIH) causes visual involvement secondary to papilledema but rarely presents with acute gross diminution of vision. Anemia is associated with IIH. Acute hemorrhage-related anemia causing severe sudden onset bilateral visual loss due to IIH has not been previously reported. A 28-year-old female attempted the first-trimester abortion by self-administration of oral drugs. She presented with bleeding per vaginum, followed by bilateral visual loss. Symptoms pertaining to intracranial hypertension were mild. Examination revealed pallor, normal hemodynamic parameters, bilaterally dilated pupils, bilateral lateral rectus palsy, and only perception of light in both eyes. Lumbar puncture demonstrated high pressures; neuroimaging was noncontributory. Blood transfusion and supportive therapy in the form of acetazolamide and pulse methylprednisolone improved her vision in the right eye to six of 24; optic nerve sheath fenestration was performed in the left eye. During follow-up, her vision improved to six of 24 (right) and two of 60 (left), respectively. The IIH can present with severe acute onset bilateral visual loss even if features of raised intracranial pressure are minimal or absent. Immediate correction of anemia and supportive measures may significantly improve visual outcomes in fulminant IIH without the necessity of surgery.

Acute cerebellar ataxia and peripheral neuropathy due to an atypical infection.

This 18-year-old boy presented to the hospital with symptoms of cerebellar dysfunction preceded by an acute febrile illness with rash. Examination showed evidence of left-sided cerebellar dysfunction and polyneuropathy. Empirical treatment for leptospirosis and scrub typhus was initiated. MRI was normal. Other organ dysfunctions in the form of thrombocytopenia and transaminitis were also observed. He recovered without sequelae. A diagnosis of acute cerebellar ataxia and polyneuropathy due to scrub typhus was made.

Empyema Tube or No Tube?

We report the case of a 36-year-old man with cirrhosis who presented with recurrent infection of his right-sided hepatic hydrothorax in the form of fever, dyspnea, and cough. The pleural fluid analysis showed transudative fluid with normal pH, lactic acid dehydrogenase, and glucose, but with Escherichia coli growth. An uncommon diagnosis of high mortality, spontaneous bacterial empyema was made. Criteria for chest tube drainage were met, but he was managed without one. He developed hospital-acquired pneumonia during his stay, but his pleural fluid showed the same characteristics. His empyema and pneumonia were managed with antibiotics and other supportive measures. On follow-up, he was readmitted on three other occasions with similar complaints and succumbed to upper gastrointestinal bleed during the fifth admission. A chest tube is not indicated in patients with spontaneous bacterial empyema unless frank pus is present.

Clinical utility of pleural fluid YKL-40 as a marker of malignant pleural effusion.

Pleural effusion is a common presenting feature of malignancy. Malignant pleural effusion is primarily diagnosed by pleural fluid cytology, pleural biopsy, and tumor markers. The glycoprotein YKL-40 is a new tumor marker that has shown to have a good diagnostic accuracy to detect malignant pleural effusion. However, there are only a few studies that have evaluated pleural fluid YKL-40 for detecting malignant pleural effusions. Hence, we conducted this study to evaluate the utility of pleural fluid YKL-40 to detect malignant pleural effusion. This is a cross-sectional study conducted between February 2016 and December 2017 in a tertiary care referral hospital. One hundred and forty-seven consecutive patients with pleural effusion were included in the study. These patients were divided into 3 groups, viz malignant, tuberculous, and parapneumonic pleural effusion, based on clinical features, radiological examination, and pleural fluid analysis. Pleural fluid YKL-40 levels were measured using enzyme-linked immunosorbent assay. Out of the 147 consecutive patients included in the study, 47 patients (31.97%) had malignant pleural effusion, 51 patients (34.69%) had tuberculous pleural effusion, and 49 patients (33.33%) had parapneumonic pleural effusion. The median pleural fluid YKL-40 level was higher in malignant pleural effusion (114.80 ng/mL) compared to tuberculous (93.17 ng/mL) and parapneumonic pleural effusion (89.87 ng/mL; P < 0.05). A diagnostic cut-off for pleural fluid YKL-40 value of 99.76 ng/mL detected malignant pleural effusion with 83% sensitivity, 87% specificity, positive predictive value (PPV) of 75%, negative predictive value (NPV) of 91.58%, and diagnostic accuracy of 85.71%. The level of pleural fluid YKL-40 is significantly elevated in malignant pleural effusion. In lymphocytic pleural effusions presenting with low adenosine deaminase levels and high YKL-40 levels, a thorough diagnostic search for malignancy is warranted.