Unravelling a Triad: A Rare Case of Takayasu Arteritis, Hashimoto's Thyroiditis, and Psoriasis in a Young Female With Heart Failure.

Takayasu arteritis (TA) is an autoimmune entity of unknown aetiology causing granulomatous thickening of large and medium-sized arteries. Common symptoms include claudication, headaches, dizziness, syncope, visual changes, and palpitations. Diverse cardiac manifestations, such as ischemic heart disease, significant aortic regurgitation, and pulmonary hypertension, are associated with TA, although they rarely manifest as congestive heart failure. Radio-imaging, including CT angiography and MR angiography, along with more invasive procedures such as conventional angiography, are often used for diagnosis. Treatment is done with corticosteroids, steroid-sparing agents, biologics, and revascularization procedures. Here, we have a case of a 17-year-old Indian female who presented to us with a complaint of abdominal pain. She was diagnosed with Hashimoto's thyroiditis a few years ago, along with a history of congestive heart failure. On general examination, blood pressure was asymmetrical in the upper limbs with the presence of bilateral carotid bruit. There was also the presence of extensive scaly lesions on the extensor surface of all four limbs, suggestive of psoriasis. Radio-imaging confirmed the diagnosis of TA. CT angiography also showed total occlusion of the celiac trunk and proximal left gastric artery, which was likely the cause of her symptoms. The patient received treatment with corticosteroids in conjunction with methotrexate, along with other supportive drugs. TA with congestive heart failure has been occasionally described in the literature, while the association of TA with psoriasis is much rarer. The simultaneous occurrence of various autoimmune diseases is common, but the triad of Hashimoto thyroiditis, psoriasis, and TA with an initial presentation of heart failure is unique. Due to the common co-occurrence of autoimmune conditions, early and thorough patient evaluation with comprehensive studies is imperative for optimal health outcomes.

A Study of Clinical Profile and Treatment in Adult Hemophilia Patients with Special Reference to the Inhibitor Levels.

Introduction Hemophilia is an uncommon, X-linked recessive bleeding condition characterized by a lack of either factor VIII or factor IX. It is more prevalent in men. Due to the substantial impact inhibitor development has on patient prognosis, the primary treatment for hemophilia is the transfusion of recombinant factors. The aim of our study is to investigate 40 adult patients with hemophilia in terms of their clinical profile, clinically relevant risk factors for inhibitor development, therapy-related aspects such as treatment duration, factor requirements, transfusion frequency, presence of inhibitors, and complications. Methods This cross-sectional observational study involving 40 patients of hemophilia over 12 years of age was conducted at a tertiary care hospital in Gujarat. Data on sociodemographic characteristics, presenting complaints, bleeding episodes, hemophilia type, and medical history were gathered over a one-year span. Patients were stratified into mild, moderate, and severe groups based on their respective levels of factor activity. Various parameters, including the frequency of factor therapy, percentage of factor concentrate, inhibitor presence, and disease and therapy-related complications, were analyzed. The distribution of patients across these parameters was calculated and illustrated using pie charts. Results Nineteen out of 40 patients were from 20 to 40 years of age. The majority of cases (n=24), however, had been diagnosed before the patients reached the age of 10. All patients were male, and half of the patients (n=20) suffered from mild disease. The most common site of bleeding was the knee joint, and 33 cases had one to 10 bleeding episodes per year. Thirty-two out of 40 patients needed less than 40 factor vial transfusions, whereas eight needed more than 40 factor vial transfusions. Two cases of severe disease were positive for inhibitors of factor VIII, whereas one patient was found to have a hepatitis B virus (HBV) infection. Conclusions Hemophilia, a rare bleeding disorder, has primarily been studied in pediatric populations. This study, however, shifts the focus toward adult individuals. Our cohort consisted exclusively of male patients, with the predominant group diagnosed with hemophilia A and falling within the age range of 20 to 40 years. Most patients had been diagnosed before 10 years of age. The primary complication observed was joint bleeding, with the knee joint being the most commonly affected site. Approximately two-thirds of cases had a history of minor trauma necessitating factor replacement, yet only 5% exhibited the presence of inhibitors.

Clinical Profile of Adult Hemophilia Patients with Special Reference to FISH and WFHPE Score: An Observational Cross-sectional Study.

BACKGROUND AND OBJECTIVES: Hemophilia is an X-linked recessive inherited disease affecting the coagulation pathway due to congenital deficiencies in either factor VIII (hemophilia A) or factor IX (hemophilia B). The clinical assessment of a patient's functional ability and the state of joint conditions is carried out by the clinicians by administering questionnaires namely the Gilbert or the World Federation of Hemophilia Physical Examination (WFH-PE) score for joint condition and Functional Independence Score in Hemophilia (FISH) for joint function. Here, we have studied the clinical profile of adult hemophilia patients with the short- and long-term complications of the disease. Additionally, the FISH score and the Gilbert score are calculated to assess functional independence and joint condition, respectively. The scores were also compared according to the severity of the disease. MATERIALS AND METHODS: An observational cross-sectional study of 40 adult hemophilia patients was carried out in Sir Sayajirao General Hospital and Medical College, Baroda, Gujarat, India, over a period of 1 year. Data regarding age, sex, and complications associated with the disease were collected in the form of a questionnaire. The overall mean and standard deviation (SD) of FISH and Gilbert scores were calculated and correlated with the severity of the disease. RESULTS: The majority of cases (19) were between 20 and 40 years, and most (24) were diagnosed in childhood. All the subjects were male and all except one had hemophilia A. Family history was seen in only half of the cases. Nine had mild, 20 had moderate, and 11 had severe disease. Around 46% of the subjects had joint arthropathy with the knee joint most affected (60%) followed by the ankle (22.5%). The mean FISH score was 27.132 ± 4.0691 with a minimum score of 15 in severe disease suggesting more functional deficit. The average Gilbert score was 7.4 ± 2.985 with a maximum score of 14 in severe disease suggesting more joint damage Interpretations and conclusion: All subjects were male and except one all had hemophilia A. Majority were between 20 and 40 years but most were diagnosed before 10 years of age and only 50% had positive family history. Arthropathy is the most common complication with the knee joint being most affected. Majority of mild hemophiliacs achieved a maximum FISH score denoting maximum functional capacity. Compared to existing studies, our study showed better FISH scores in moderate hemophiliacs suggesting more functional independence. While comparing Gilbert's score to other studies, moderate and severe hemophiliacs in our study showed less joint damage.

Monosodium Glutamate (MSG) Symptom Complex (Chinese Restaurant Syndrome): Nightmare of Chinese Food Lovers!

Chinese food, containing the ingredient monosodium glutamate (MSG) as the main additive agent, results in a variety of symptoms in susceptible individuals. The spectrum of symptoms ranges from headache, sweating, abdominal pain, and urticaria to angioedema in severe cases. This group of symptoms is known as MSG symptom complex or Chinese restaurant syndrome (CRS). We reported one such case with unique dermatological manifestations in a young male, developed on the consumption of Chinese food, noticed first-time as per our knowledge. An adolescent male presented to the Emergency Department with high-grade fever, cough, shock, congested throat, and generalized skin rashes. After giving the history of ingestion of Chinese food prior to symptom onset, we suspected him of a case of CRS; our diagnosis was further supported by raised absolute eosinophil count (AEC) and immunoglobulin E (IgE) levels in the blood. The patient was given intramuscular adrenaline and intravenous corticosteroid in the emergencys department for anaphylaxis, followed by oral antihistaminic.

Liver Involvement in Individuals with Obesity: A Cross-sectional Study from Western India.

BACKGROUND: Obesity is a largely neglected health problem in developing countries which leads to additional morbidities including nonalcoholic fatty liver disease (NAFLD), one of the most important causes of chronic liver disease. Central obesity is intricately related to the pathogenesis of the NAFLD, which over time could result in a fiogenic response and end-stage liver disease. We have attempted to study the association of various risk factors and laboratory investigations with the incidence of liver involvement in obese individuals. MATERIALS AND METHODS: A cross-sectional study of 210 patients was carried out in a tertiary care center in Western India. Patients above 18 years of age with either general or abdominal obesity were included and their history taking and general and systemic examination was done along with laboratory investigations and ultrasonography for visualize any liver involvement. RESULTS: Age >50 years, female gender, postmenopausal state, sedentary lifestyle, high body mass index (BMI), waist circumference (WC), and neck circumference were all risk factors for liver involvement in obese individuals. Raised C-reactive protein (CRP), serum glutamic-oxaloacetic transaminase (SGOT), triglycerides, low density lipoprotein (LDL), cholesterol, fasting blood sugar (FBS), 2-hour postprandial blood sugar (PP2BS), and low high density lipoprotein (HDL), serum protein, and albumin were significantly associated with liver disease. Patients having high NAFLD fiosis and BMI, aminotransferace ratio and diabetes (BARD) scores, or Metabolic syndrome (MS) was at a higher risk for liver disease. CONCLUSION: Advancing age, postmenopausal females, and lack of physical activity are risk factors for liver disease in obesity. Raised CRP and SGOT along with impaired lipid profile and glycemic control could be used as markers for fatty liver in obese individuals. MS greatly increases the risk of liver involvement in obese individuals.

A Triad of Trichobezoar: Rapunzel Syndrome, Severe Malnutrition, and Cerebral Venous Thrombosis.

Trichobezoar is a rare condition almost exclusively seen in young females presenting with non-specific abdominal complaints and a history of psychiatric illness. In most patients, it is confined within the stomach; however, in some severe cases, it extends through the pylorus into the duodenum, jejunum, ileum, or even colon, known as Rapunzel syndrome. Conventional treatment includes laparotomy and psychiatric counseling to prevent relapses. We report the case of an 18-year-old female with no previous history of medical or psychiatric illness who presented with chief complaints of upper abdominal pain, nausea, occasional vomiting for the last six months, and generalized edema for the last three days. On examination, pallor, anasarca, and a palpable abdominal lump were present. On blood investigations, severe malnutrition was seen in the form of severe iron deficiency anemia and severe protein deficiency. Radiological evaluation revealed a large trichobezoar on the CT abdomen and endoscopy, whereas CT venography of the brain, done for persistent headache, showed hyperdense thrombi in the cortical veins. Exploratory laparotomy was done to remove trichobezoar, followed by medical management of malnutrition, cerebral venous thrombosis (CVT) with anticoagulants, and psychiatric counseling for trichobezoar. The association between trichobezoar, malnutrition, and CVT in our case is a further area of research.

Clinical Profile and Outcome of Critically-ill Hospitalized COVID-19 Patients Aged 18-50 Years: A Limited Resource Setting Perspective.

OBJECTIVES: The coronavirus disease of 2019 (COVID-19) pandemic started by affecting the older age groups with comorbidities but gradually advanced to severely affect even young adults. This study attempts to clinically evaluate critically ill young and middle-aged adults hospitalized with COVID-19 and study the association of risk factors and the markers of inflammation and coagulation with their outcome. MATERIALS AND METHODS: A prospective observational study on 146 patients was conducted in a tertiary care hospital in Western India. History taking, clinical examination, laboratory investigations, and chest X-rays were done for all patients, and investigations were repeated after 3 days. Treatment, including ventilation, was given according to standard guidelines. RESULTS: Difficulty in breathing was the most common chief complaint, and the majority of patients had a normal body temperature on admission. Involvement of >2 lung zones on chest X-ray, a high neutrophil to lymphocyte (N/L) ratio, the presence of complications, raised D-dimer and serum ferritin, and invasive ventilation were all associated with higher mortality. While the presence of a single comorbidity did not affect the outcome, a combination of multiple comorbidities increased the mortality. CONCLUSION: The presence of multiple comorbidities and complications along with radiological abnormalities and raised D-dimer and serum ferritin are associated with critically ill COVID-19 patients and may indicate a higher risk of mortality. Administration of remdesivir has no significant influence on the outcome, but tocilizumab decreases the mortality. The inflammatory markers scoring system has utility in the prognosis of patients, especially in limited-resource settings.

Mucormycosis, Diabetes and COVID-19 Pneumonia: Unleashing the Facts.

Background Mucormycosis (MM) is an angioinvasive locally destructive fungal infection. Before the coronavirus disease 2019 (COVID-19) pandemic, it was associated with diabetes (particularly diabetic ketoacidosis), immunosuppressive drugs and trauma. Among its various forms, cerebral invasion is considered to be highly fatal even if with long-term treatment. Treatment with injection amphotericin B (Amph-B) with early surgical interventions is highly efficacious. Liposomal preparation is considered to be superior in the context of fewer side effects. Methods We present a single-centre prospective study of 124 patients with MM in a tertiary care hospital. After the approval from the ethics committee, basic information was taken from all patients including all available past history about the COVID-19 infection and treatment. The studied outcomes were discharge, death and number of days of hospitalisation. Secondary objectives were to estimate the association of MM with known risk factors, to find the association of an outcome with various inflammatory markers, to determine adverse events with the use of injection Amph-B and posaconazole and to find the case fatality rate of MM. Results In our study, we observed that the number of patients with MM was double in the less than 60 years age group. However, mortality was 33.3% in the elderly as compared to 15.29% in patients less than 60 years of age. The majority of the patients (69.35%) were males, but no significant difference in mortality was seen between males and females. The case fatality rate was 20.97%. Ocular symptoms such as orbital swelling and pain were the common presenting symptoms. Almost all patients (93.54%) were diabetics. The non-diabetic group consisted of only 8 (6.4%) patients, and therefore, the comparison was not possible. A total of 20 (16%) out of 124 patients who had received high-dose steroids showed higher mortality (55%). Maximum patients (65.32%) had presented with MM following a past COVID-19 infection. However, a significant number of MM patients (20.96%) had a recent COVID infection and had higher mortality (57.69%) compared to their counterparts. The most common site of involvement in our study was the paranasal sinus (50%) and the outcome was the best in those patients whose disease was localised only to the sinuses, although among 14 (11.29%) patients with cerebral involvement, mortality was maximum (42.85%). Renal impairment and dyselectrolytemia were the most common adverse effects of Amph-B, and 46.42% of patients required surgical removal of the local part. Conclusion We saw that diabetes was a major contributory factor in the etiopathogenesis of MM. COVID-19 could also be a major causative factor by impairing the immune system; however, further studies at the molecular level are required to establish an association. The use of steroid cannot be the only independent risk factor, and other associated factors must be present. Treatment with antifungal and early surgical intervention had good outcomes. Treatment with conventional lyophilized Amph-B was equally efficacious as lipid-based solutions, but with more side effects. Hypokalemia and hypocalcemia were the most common electrolyte abnormalities associated with the use of injection Amph-B. Uncontrolled diabetes, the severity of the COVID-19 infection at presentation, acidosis, a high C-reactive protein level (above 100) and local brain involvement were associated with a poor outcome.

Adjuvant Tocilizumab in the Treatment of Patients with Moderate to Severe COVID-19 Pneumonia: An Observational Study.

IMPORTANCE: As there is no definitive treatment available for covid-19 pneumonia, with timed administration of tocilizumab as an adjuvant therapy in moderate to severe covid-19 pneumonia, we can reduce mortality due to cytokine storm. OBJECTIVE: To determine effectiveness of tocilizumab as an adjuvant therapy in moderate to severe covid-19 pneumonia patients. DESIGN: Retrospective Observational study from the time period of April 2020 to December 2020. SETTING: This study has been carried out at SSG Hospital, a tertiary care hospital at Vadodara, Gujarat. PARTICIPANTS: 80 moderate to severe COVID-19 positive patients in the group of age 18-80 years requiring hospitalisation in whom tocilizumab (8mg/kg to a maximum dose of 800mg) was given, were enrolled in the study. The following patient details were collected and studied in relation to the use of tocilizumab- Biodata, Presenting complaints, past history of any illness, Drug history, Vitals and physical examination, Investigations, Treatment. Exposures: 80 patients of moderate to severe COVID-19 pneumonia who were given Injection tocilizumab (8mg/kg to a maximum dose of 800mg) were selected retrospectively. Main outcomes and Measures: We have correlated the outcome in the form of discharged or death with the help of parameters likes: Time to Clinical Improvement, Ventilator-Free Days, Duration of ICU Stay, Time to Clinical Failure, and Time to Hospital Discharge. RESULTS: Out of the total 80 patients, 29 patients were in the age group of more than 60 years, of which 7 were discharged and 22 died. The other 51 patients were less than 60 years of age, of which 28 patients were discharged and the rest 23 died. (p value 0.007). 63 patients out of the total 80 patients were males of which 31 (49.21%) recovered while 32 (50.79%) of them died. 5 (29.11%) females out of the total 17 female covid positive patients recovered while the other 12 (70.59 %) died. (p value 0.14). Conclusion and Relevance: In our study, we have observed that even after giving tocilizumab mortality was higher in patients above 60 years of age, two or more co-morbidities, SpO2 of less than 85% on the room air, SOFA scoring of more than or equal to 3, radiological involvement of more than 2 zones, higher score (>3) of inflammatory markers, higher level of mode of respiratory support like BiPAP or invasive ventilation. . This shows that the ideal time to give tocilizumab is when the patient is on NRBM support. By this it gives the maximum benefit. There was no difference in outcome in patients of either gender, blood pressure and on admission blood sugar levels, and co-administration of injection Ramdesivir. Significant percentage of patients died who had uncontrolled diabetes mellitus with insignificant p value, so further studies are required to find out the association.

Efficacy of tocilizumab in treatment of COVID-19 pneumonia: A case-control study from a tertiary care hospital.

Background and Objective: Coronavirus disease 2019 (COVID-19) is a viral infectious disease caused by the severe acute respiratory syndrome virus, which has affected billions of people across the globe. The pathogenesis of respiratory inflammation involves elevated concentration of interleukin-6; hence, interventions targeting interleukin-6 receptor, such as tocilizumab (TCZ), have been investigated as potential treatment amidst the dilemma of COVID-19 management. The aim of the study is to analyse the efficacy and safety of TCZ and record the outcome in COVID-19 patients. Materials and Methods: A retrospective case-control study of 80 patients in each group (N = 160) was carried out in a tertiary care hospital in Vadodara, Gujarat. Non-pregnant COVID-19-positive patients above 12 years of age were included in the study and were divided into case (those given TCZ) and control (those given standard treatment) groups after collecting their history and related data. From each group, further data was collected in the form of general and systemic examination, investigations and calculation of inflammatory and Sequential Organ Failure Assessment (SOFA) scores. Results: Overall mortality was less in the case group compared to the control group. Patients with moderate to severe disease, age <55 years, patients having no comorbidity and patients with higher oxygen demand had lower deaths when given TCZ. Inflammatory score <3 and SOFA score <6 were associated with reduced mortality in the case group. Additionally, the study found significant results by simultaneously analysing two parameters in combination, which has not been done in any other study to the best of our knowledge. Conclusions: Adjuvant TCZ therapy had overall mortality benefit compared to standard treatment, with specific benefit observed in those with increasing disease severity, young to middle-age group, absence of comorbidity, higher oxygen requirements and lower inflammatory and SOFA scores.

Association of Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) and Thyroglobulin (TG) Genetic Variants with Autoimmune Hypothyroidism.

Autoimmune hypothyroidism is known to be caused by immune responses related to the thyroid gland and its immunological feature includes presence of autoimmune antibodies. Therefore the aim was to analyze presence of anti-TPO antibodies in hypothyroidism patients in Gujarat. Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) is one of the susceptibility genes for various autoimmune diseases. Hence, exon1 +49A/G and 3'UTR CT60A/G single nucleotide polymorphisms (SNPs) in CTLA4 and its mRNA expression levels were investigated in autoimmune hypothyroidism patients. Thyroglobulin (TG) is known to be associated with autoimmune thyroid disorders and thus exon 33 (E33) SNP in TG was investigated. We analyzed the presence of anti-TPO antibodies in the plasma samples of 84 hypothyroidism patients and 62 controls by ELISA. PCR-RFLP technique was used for genotyping of polymorphisms. sCTLA4 and flCTLA4 mRNA expression levels were assessed by real time PCR. 59.52% of hypothyroid patients had anti-TPO antibodies in their circulation. The genotype and allele frequencies differed significantly for +49A/G (p = 0.0004 for +49AG, p = 0.0019 for +49GG & p = 0.0004 for allele), CT60 (p = 0.0110 for CT60AG, p = 0.0005 for CT60GG & p<0.0001 for allele) and TG E33 (p = 0.0003 for E33TC p<0.0001 for E33CC& p<0.0001 for allele) SNPs between patients and controls. Patients had significantly decreased mRNA levels of both sCTLA4 (p = 0.0017) and flCTLA4 (p<0.0001) compared to controls. +49A/G and CT60 polymorphisms of CTLA4 were in moderate linkage disequilibrium. Logistic regression analysis indicated significant association of CT49A/G, CT60A/G and TG exon 33 polymorphisms with susceptibility to autoimmune hypothyroidism when adjusted for age and gender. Our results suggest +49A/G and CT60 polymorphism of CTLA4 and E33 polymorphism of TG may be genetic risk factors for autoimmune hypothyroidism susceptibility and down regulation of both forms of CTLA4 advocates the crucial role of CTLA4 in pathogenesis of autoimmune hypothyroidism.

Cortical venous thrombosis presenting with subarachnoid haemorrhage.

BACKGROUND: Our study retrospectively reviewed the presentation, neuro-radiological findings, and outcomes of eight adult patients presenting at our institution with subarachnoid haemorrhage (SAH), which was subsequently proven to be due to cortical venous thrombosis (CVT). METHODS: We reviewed the case records and neuroimaging findings of eight patients diagnosed with SAH and CVT over a span of two years at our institution, a tertiary care centre in Western India. All details pertaining to their presentation, clinical findings, neuroimaging, management, and outcome following therapy with anticoagulants were collected until patient discharge. RESULTS: There were a total of eight patients, with the average age being 34 years (range 25-42). Only one patient was female. Six patients had a history of recent binge drinking. None of the patients had a past or family history of common risk factors for thrombosis. All patients presented acutely, with headache (n=6) and seizures (n=6) being the most common presenting features, occurring in three-quarters of the patients examined. Non-contrast computed tomography (NCCT) was the initial imaging study for all but one of the patients and showed cortical SAH (cSAH) without basilar haemorrhage. Magnetic resonance imaging/magnetic resonance venography (MRI/MRV) confirmed the underlying CVT. Unfractionated heparin was used in all cases. Seven patients improved and were discharged on oral anticoagulation. The eighth patient died. CONCLUSION: Localised cSAH with sparing of basal cisterns can be a presentation for CVT. In patients with cSAH, MRI/MRV can be useful to make a diagnosis of CVT. Anticoagulation for CVT, even in the presence of SAH was related to seven out of eight patients being discharged.

Symmetrical peripheral gangrene following snake bite.

SPG (Symmetrical peripheral gangrene) is defined as symmetrical distal ischemic damage at two or more sites in the absence of large vessels obstruction. It has been ascribed to a number of infectious and non infectious conditions including connective tissue, cardiovascular, neoplastic and iatrogenic causes. We report a unique case of SPG in a 35-year-old Indian female who developed spontaneous gangrene of the distal phalanges of the right and left index, middle, ring and little fingers and the distal phalanges of all toes of the right and left foot following a snake bite. There have been very few cases of peripheral gangrene and acute renal failure associated with snake bite in literature.

Portal vein Doppler: a tool for non-invasive prediction of esophageal varices in cirrhosis.

BACKGROUND AND OBJECTIVES: Esophageal varices (EV), a major complication of liver cirrhosis, can lead to life threatening gastrointestinal (GI) bleeding. Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis and management of esophageal varices. However, it is not always available in resource-constrained settings.This study was aimed at evaluating portal vein indices (PVI) using Doppler on ultrasound abdomen, which is more widely available, as tools to predict the presence of EV. METHODS: A total of 50 adult patients with cirrhosis were included in the study. All subjects underwent a percutaneous liver biopsy, abdominal ultrasound and EGD along with other tests as part of the work up for cirrhosis. The portal vein indices that were studied included hepatic congestion index (HCI), portal vein diameter (PVD) and portal vein velocity (PVV). Their sensitivity, specificity and predictive values were calculated using EGD as a gold standard. RESULTS: Association of PVD, PVV and HCI with presence of EV was statistically significant (p-value <0.01). PVV had the highest sensitivity 84% (95% CI 66.45%- 94.10%) for detecting the presence of EV. PVD and HCI had the highest specificity of 55% (95% CI 0.31-0.77) and the highest negative predictive value of 38%(95% CI 0.24-0.52). Positive predictive value was highest PVV at 76%. (95% CI 0.61-0.86). CONCLUSION: In resources- constricted settings where EGD is not available, PVI (PVV, PVD and HCI) on ultrasound abdomen can be used as non-invasive parameters to predict the presence of EV. Although EGD remains the gold standard for the diagnosis and management of EV, when this is not possible due to scarcity of resources, PVV may be used a tool to triage patients for referral for an EGD as it has the highest sensitivity of 84% (95% CI 66.45%-94.10%) and positive predictive value of 76% (95% CI 61.51%-86.47%) amongst the PVI studied for detecting the presence of EV.

Isolated hepatic tuberculosis: An uncommon presentation of a common culprit.

Hepatic tuberculosis (HTB) is commonly encountered in patients with widespread miliary disease. Isolated affection of the liver is extremely rare. We present a case of a young woman who presented with a subacute afebrile hepatic failure. Investigations including a liver biopsy proved that the presentation was due to granulomatous hepatitis secondary to mycobacterial infection of the liver. It is important that tuberculosis (TB) be kept in mind especially in endemic areas even in atypical clinical scenarios by clinicians, radiologists, and pathologists. Use of anti-tuberculous drugs in such cases is usually successful and must be instituted early.