Sterile Endocarditis and Splenic Infarct: A Rare Masquerading Presentation of Granulomatosis With Polyangiitis in a Patient With Pulmonary Aspergillosis.

Granulomatosis with polyangiitis (GPA) is a rare multisystem disease characterized by vasculitis affecting small vessels, resulting in the formation of necrotising granulomata, primarily affecting the lungs, the upper respiratory tract, and kidneys. Almost all patients have upper and lower respiratory involvement; up to 85% of patients with GPA develop kidney disease within two years of diagnosis. Cutaneous, neurological, and ocular manifestations are also seen with varying frequencies. However, cardiac manifestations of the disease are rare and scarcely reported in the literature. Here, we report a case of a 65-year-old female with an initial diagnosis of pulmonary aspergillosis based on the presence of septate hyphae branching at acute angles on lung biopsy and elevated serum galactomannan, who, over the following months, developed a multitude of issues such as myocardial infarction, sterile endocarditis, splenic infarction, and heart block, as well as the challenges faced in establishing a diagnosis and managing its complications.

A Case Report of Hereditary Palmoplantar Keratoderma with Esophageal Melanosis.

A 70-year-old man, a known case of diabetes mellitus since 10 years ago, presented with lower limb swelling and dyspnea on exertion for one month and dysphagia to solids associated with early satiety for 2 weeks. The patient had palmoplantar keratosis (PPK), which was present since birth with a similar family history. The patient was admitted to rule out esophageal malignancy. Upper gastrointestinal gastroscopy revealed esophagitis and esophageal melanosis with gastric mucosal erythema. Biopsies samples were taken. Histopathological examination revealed reflux esophagitis and chronic active Helicobacter pylori gastritis with no evidence of malignancy. His symptoms improved following H. pylori eradication and treatment for coronary artery disease and heart failure. The patient was advised of regular follow-up as he had risk factors for the development of esophageal melanoma or squamous cell carcinoma.

Comparison of Fasting Insulin Level, Homeostatic Model of Insulin Resistance, and Lipid Levels between Patients with Primary Hypertension and Normotensive Subjects.

BACKGROUND: Hyperinsulinemia and insulin resistance occurs in obese patients with primary hypertension independent of diabetes and obesity. This study was aimed at assessing serum fasting insulin levels, the homeostatic model assessment for insulin resistance (HOMA-IR), and serum lipid levels in non-obese patients with primary hypertension when compared to normotensive subjects. METHODS: This observational study comprised 100 patients over 18 years of age, divided into two groups. The hypertensive group comprised non-obese patients with primary hypertension (n=50); the normotensive group comprised normotensive age- and sex-matched individuals (n=50). Patients with diabetes, impaired fasting glucose, obesity, and other causative factors of insulin resistance were excluded from the study. Serum fasting insulin levels and fasting lipid profiles were measured, and insulin resistance was calculated using HOMA-IR. These data were compared between the two groups. Pearson's correlation coefficient was used to assess the extent of a linear relationship between HOMA-IR and to evaluate the association between HOMA-IR and systolic and diastolic blood pressures. RESULTS: Mean serum fasting insulin levels (mIU/L), mean HOMA-IR values, and fasting triglyceride levels (mg/dL) were significantly higher in the hypertensive versus normotensive patients (10.32 versus 6.46, P<0.001; 1.35 versus 0.84, P<0.001; 113.70 versus 97.04, P=0.005, respectively). The HOMA-IR levels were associated with systolic blood pressure (r value 0.764, P=0.0005). CONCLUSION: We observed significantly higher fasting insulin levels, serum triglyceride levels, and HOMA-IR reflecting hyperinsulinemia and possibly an insulin-resistant state among primary hypertension patients with no other causally linked factors for insulin resistance. We observed a significant correlation between systolic blood pressure and HOMA-IR.

The requirement of hemodialysis in patients with acute gastroenteritis-induced acute kidney injury.

Acute gastroenteritis is an important cause of preventable acute kidney injury (AKI). Inadequate or delayed restoration of diarrheal losses results in a very high incidence of AKI. Diarrheal illness is a major reason for hospitalization, but data on consequent acute kidney injury are sparse. The objective of the study is to determine the incidence of AKI in infectious and noninfectious diarrheal illness requiring hospitalization and to identify correlates and outcomes of diarrhea-associated AKI. None of the patients had any organism isolated in stool, probably due to prompt initiation of antibiotics/inadequate culture growth. Three out of our 6 cases did not require hemodialysis (HD) and AKI resolved on conservative management alone (fluids, electrolyte management, and antibiotics). Three out of 6 cases had nonresolving AKI and were dependent on renal replacement therapy (RRT) even at 1 month after discharge as they remained oliguric. One recent paper has reported the recovery of renal function after a period of dialysis. Frequent electrolyte abnormalities, risk of (catheter-related/bloodstream) infections, and severity of the primary disease are the chief reasons for the persistently high morbidity. Although, there was no mortality in our study.

Hypertensive retinal changes, a screening tool to predict microalbuminuria in hypertensive patients: a cross-sectional study.

BACKGROUND: Studies have shown that hypertensive retinal changes (HRC) have a moderate accuracy in predicting microalbuminuria (MA) in elderly hypertensive patients (age >65 years). This study is an effort to identify a similar relationship in hypertensive patients aged <65 years. METHODS: Eight hundred and seventy consecutive hypertensive patients (males, 460; females, 410) aged 18-65 years were assessed for their demographic characteristics and other laboratory variables. Patients with diabetes mellitus, metabolic syndrome and overt nephropathy were excluded. Optic fundi were assessed for HRC after pupillary dilatation, which were photographed. MA (albumin-creatinine ratio) was measured as an average of two non-consecutive overnight spot urine samples. RESULTS: Mean age was 45 +/- 13.4 years. Prevalence of MA and HRC was 36.7 and 38%, respectively. MA showed a strong association with HRC (P < 0.0001). Logistic regression identified the association between MA, duration of hypertension (HTN) (P = 0.016), smoking (P = 0.012) and elevated high-sensitivity C-reactive protein (HsCRP) (P = 0.032). HRC were associated with duration of HTN (P = 0.021) and smoking (P < 0.0001). Tests of accuracy for HRC as a predictor of MA showed sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio of a positive test and likelihood ratio of a negative test of 78%, 86%, 76%, 87%, 5.2 and 0.26, respectively. Area under the receiver operating characteristic curve was 81%. Similarly, the individual grades of HRC had a moderate predictive accuracy. Higher grades had higher predictive accuracy. Inter- and intra-observer correlation in interpreting HRC was acceptable. CONCLUSIONS: HRC of any grade have moderate accuracy in predicting MA and hence can be used as a cost-effective screening tool to predict MA especially in a resource-poor setting.

Multidrug resistant tuberculosis co-existing with aspergilloma and invasive aspergillosis in a 50 year old diabetic woman: a case report.

Aspergilloma and invasive aspergillosis coexisting with multidrug resistant Mycobacterium tuberculosis (MDR-TB) in the same patient is a rare entity. We report a 50 year old South Indian woman, a diabetic, who presented to us with complaints of productive cough and hemoptysis for the past 2 months. She was diagnosed to have pulmonary tuberculosis 2 years ago for which she took irregular treatment. Lung imaging showed features of a thick walled cavity in the right upper lobe with an indwelling aspergilloma. She underwent a right lung upper lobe resection. Biopsy and culture of the resected specimen showed the coexistence of Aspergillus fumigatus and multi-drug resistant Mycobacterium tuberculosis. 2 blood cultures grew Aspergillus fumigatus. She was successfully treated with Voriconazole and anti tuberculous therapy against MDR-TB.