Spontaneous Hypoglycemia in a Non-diabetic Patient: A Diagnostic and Therapeutic Conundrum.

Hypoglycaemia is a medical emergency requiring an immediate intervention to prevent neuroglycopenic symptoms such as confusion, seizures, and coma. While evaluating for the cause of hypoglycemia, after excluding common causes like insulin use or sepsis, other causes involving endogenous hypoglycemia need to be evaluated. A cause to be considered is nesidioblastosis. This rare entity is also known as non-insulinoma pancreatogenous hypoglycemia syndrome. There have been instances where this disorder has been mistaken as insulinoma due to the characteristics shared by the two. Here, we present a case of a non-diabetic male experiencing symptoms of giddiness and palpitations for the past two years who had been extensively evaluated to rule out insulinoma and was diagnosed with nesidioblastosis.

Reversible Second-Degree Heart Block Attributed to Ondansetron: A Rare Side Effect.

A primigravida at 36 weeks with gestational diabetes mellitus and hypothyroidism and no prior chronic medical illness was admitted for safe confinement. A cesarean section was required to deliver the baby with breech presentation complicated by a slow progression of labor. Asymptomatic sinus bradycardia with a heart rate of 40 per minute was observed during the induction of anesthesia. Before bupivacaine administration for spinal anesthesia, she was administered pantoprazole 40 mg and ondansetron 4 mg intravenously. ECG recording showed a type 1 Mobitz second-degree heart block. Follow-up ECG showed progression of heart block to type 2 Mobitz second-degree heart block. The second-degree heart block persisted for 16 hours, during which the patient was asymptomatic, and the ventricular rate was maintained at a range of 60-80 per minute. After normalization of rhythm, the patient was observed in the ICU. She received another dose of ondansetron 4 mg intravenously for vomiting, and the heart block recurred. The rhythm disturbance was attributed to ondansetron. Her rhythm normalized after 36 hours, and she was subsequently discharged home three days later.

Unveiling the Neurotoxicity of Metronidazole: A Clinical Conundrum.

Metronidazole, a commonly used antiprotozoal agent, has been linked to neurotoxicity in a few individuals. We present the case of a 61-year-old gentleman diagnosed with a liver abscess, who received a total dose of 64 g of metronidazole over a four-week duration. He subsequently developed slurred speech, numbness, and tingling sensation in both feet. His neuroimaging revealed T2 hyperintensities in the bilateral dentate nuclei and withdrawal of the drug led to symptomatic improvement in the patient. Metronidazole is known to produce neurological manifestations with involvement of peripheral nerves and cerebellum commonly. In the present case, the cumulative dose impact of metronidazole on the dentate nucleus was evident.

The Effect of Glycemic Status on P Wave Dispersion.

Background and aim The growing number of people with diabetes mellitus (DM) across the world is a public health concern. The diabetes epidemic involves enormous health costs to the patients, their careers, and society at large. Cardiovascular diseases such as atrial fibrillation (AF) often develop in the diabetic population. An increase in the P wave dispersion (PWD) has been established as an independent risk factor for the occurrence of AF, hence the present study was conducted to establish a possible relationship between PWD and the glycemic status of the individual to predict the occurrence of AF ahead of clinical symptomology. Methodology A comparative cross-sectional study was conducted at a tertiary care hospital after obtaining approval from the institutional ethics committee and written consent of each study subject. The main steps included the selection and categorization of the study population based on their glycemic status, collection of demographic data, performing ECGs calculating PWD using digital calipers, and recording the data systematically for evaluation. Results In this study, 234 patients with a mean age of 53.3 ± 13.1 years were studied, of which 121 (51.7%) were male and 113 (48.29%) were female. The 234 patients were divided into four groups based on their glycemic status - 74 uncontrolled DM patients (31.62%), 51 type 2 DM (T2DM) patients (21.78%), 56 prediabetes patients (23.93%), and 53 patients in the control group (22.64%; not a known case of diabetes with normal HbA1c and fasting blood sugar (FBS) levels). Minimal correlation was observed between FBS with PWD (r value 0.175) and age with PWD (r value 0.161), but statistical significance was observed only between age and PWD (p-value 0.014). The difference in means between the four different study groups was found to be not statistically significant (p-value- 0.104); hence, no intergroup variation was noted. Conclusion Advancing age and higher fasting blood sugars have shown minimal correlation with widening P-wave dispersion. With further studies involving larger populations, this can be a promising aid in identifying PWD as a probable early predictor of atrial arrhythmias among diabetic patients.

Risk association of the nitric oxide synthase VNTR intron 4 a/b variant with diabetic nephropathy - a pilot study.

Diabetic nephropathy (DN) is known to be a leading complication of type 2 diabetes mellitus (T2D). This study evaluated whether the VNTR intron 4 a/b and rs1799983 polymorphisms of endothelial-derived nitric oxide synthase (eNOS) gene modulated the risk of developing DN in Asian Indian patients. The eNOS variants were genotyped in 200 patients, 100 with DN and 100 without DN. A significant risk association was observed for the VNTR intron 4 a/b (p < 0.05). Haplotype analysis revealed that the allele combination of rs1799983894 G/Intron 4b and rs1799983894 T/Intron 4b had a statistically significant inverse association with DN.

Recurrent Young Stroke With Hemianopia.

Homocysteine is a toxic, sulphur-containing intermediate of methionine metabolism. Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke. We present the case of a 39-year-old male who sustained a cerebrovascular accident with left hemiparesis two years back; the patient was not compliant with his medications, and now presented with complaints of giddiness, reduced vision, and double vision. Vision disturbances were bilateral, acute in onset, progressive over time, and predominantly affected the peripheral vision. On ophthalmic examination, homonymous hemianopia was noted, and finger counting was absent in both eyes. Confrontation test revealed a bilateral reduced field of vision more so in the left eye. Baseline investigations were unremarkable except for mildly elevated serum. Homocysteine and neuroimaging showed acute infarct with hemorrhagic transformation in the right occipito-parietal region and small acute non-hemorrhagic infarcts in the right thalamus and right side of the splfingerenium of the corpus callosum. Given the visual disturbance, Humphrey visual field (HVF) perimetry was done and it revealed left homonymous congruous hemianopia, likely due to right parietal lobe infarct. The patient had recurrent infarcts previously involving anterior and posterior circulation.

Chyluria in a Postpartum Obese Female Patient.

Chyluria characterized by the passage of milky white urine is rarely encountered these days due to the overall reduction in the number of cases of lymphatic filariasis. Though lymphatic filariasis accounts for the majority of cases of chyluria, nonparasitic causes have also been reported. Case reports of chyluria as a complication in pregnancy have been published but chyluria presenting solely as a postpartum complication has rarely been documented. We present a case of a 29-year-old female with no known prior comorbidities, who presented with recurring complaints of the painless passage of milky white urine over the last year. Symptoms seem to have started six months post-delivery of her second child. The patient claimed significant weight gain during an otherwise normal pregnancy. She was well-built and had a BMI of 32 kg/m2. Her systemic examination and baseline laboratory workup were within normal limits. Postprandial urine was milky white, rich in chylomicrons, with urine chylomicrons of 112 mg/dl. The patient was screened for filariasis, which was negative. An ultrasound of the abdomen was done to rule out the presence of a fistula, but no evidence of one was found on imaging. Tc-99m sulfur colloid scintigraphy revealed an area of abnormal tracer accumulation in the abdomen with the passage of the tracer in the urine container, confirming the presence of chyluria. The patient was recommended to undergo conservative management with dietary modification and weight reduction. She has been closely followed up and has achieved spontaneous resolution of the chyluria. Most patients with chyluria show a good response to conservative management alone as in our case. Surgical intervention is usually indicated for cases not responding to conservative management or for refractory chyluria.

Candidate Gene Expression in Regional Population and Its Relevance for Radiation Triage.

Quantification of gene expression signatures has been substantiated as a potential and rapid marker for radiation triage and biodosimetry during nuclear emergencies. Similar to the established biodosimetry assays, the gene expression assay has drawbacks such as being highly dynamic and transient, not specific to ionizing radiation, and also influenced by confounding factors such as gender, health status, lifestyle, and inflammation. In view of that, prior knowledge of baseline expression of certain candidate genes in a population could complement the discrimination of the unexposed from the exposed individuals without the need for individual pre-exposure controls. We intended to establish a baseline expression of reported radiation-responsive genes such as CDKN1A, DDB2, FDXR, and PCNA in the blood samples of healthy human participants and then compare it with diabetic/hypertension participants (as a chronic inflammatory condition) drawn from south Indian population. Further, we have examined the appropriateness of the assay for radiation triage-like situations; i.e., the expression profiles of those genes were examined in the participants who underwent X-ray-based medical imaging. Acute inflammation induced by lipopolysaccharide exposure in the blood significantly increased the fold expression of those genes (p < 0.0001) compared to the control. Whereas the basal expression level of those genes among the participants with the inflammatory condition is marginally higher than those observed in the healthy participants; despite the excess, the fold increase in those genes between the groups did not differ significantly. Consistent with the inflammatory participants, the basal expression level of those genes in the blood sample of participants who received X-radiation during neuro-interventional and computed tomography imaging is marginally higher than those observed in the pre-exposure of respective groups. Nevertheless, the fold increase in those genes did not differ significantly as the fold change fell within the two folds. Thus, overall results suggest that the utility of CDKN1A, DDB2, FDXR, and PCNA gene expression for radiation triage specific after very low-dose radiation exposure needs to be interpreted with caution for a much more reliable triage.

Unusual cause of seizures: Imported fire ant bite reaction.

Imported fire ant (IFA) species can lead to a lot of allergic manifestations. This can vary from pustular eruptions at the bite site to anaphylactic shock, cardiac, and neurological manifestations. We are presenting an unusual manifestation of ant bite - a 56-year-old woman who developed seizures following a bite of IFA. She experienced an ant bite on her back following which she developed seizures. She had a similar episode 5 years back following ant bite (similar in appearance). This being an unusual presentation, was treated as a primary seizure disorder. She had discontinued therapy due to allergic reaction to the anti-epileptic drug. On presentation to our hospital, she was screened for organic causes for seizures that were negative. Her description of the ant matched with that of IFA - Solenopsis invicta and was confirmed by physical verification. The patient was advised about avoidance of ant bites, using fully covered clothing at the workplace.

Uncommon Cardiac Metastasis in Common Carcinoma Colon.

Colon carcinoma (CA) is one of the most common cancers worldwide. Cardiac metastasis in CA is quite rare with only a few incidences. These tumors are usually clinically silent and are discovered on autopsy. We present a case of a 62-year-old woman, known diabetic, hypertensive, and hypothyroid patient, who presented with complaints of abdominal distention and obstipation with multiple episodes of vomiting undigested food particles for three days. She had been passing dark tarry stools infrequently for over a month. She complained of a progressive loss of appetite and 5 kg weight loss over a month. Her examination revealed pallor and irregular pulse with a rate of 94/min. She had a distended non-tender abdomen and absent bowel sounds. Contrast-enhanced computed tomography (CECT) abdomen showed circumferential thickening of the descending colon, causing acute stenosis with multiple liver metastases and enlarged pericolic lymph nodes. Serum carcinoembryonic antigen (CEA) was elevated, 55.45 ng/mL. She underwent an emergency exploratory laparotomy with transverse loop colostomy. Histopathology report showed moderately differentiated adenocarcinoma. ECG showed atrial fibrillation and two-dimensional echocardiogram showed right ventricular metastasis. High-resolution computed tomography (HRCT) thorax was done to confirm the diagnosis. The common sites of metastases from colorectal cancer are the lymph nodes, liver, and lungs. When cardiac metastasis occurs, it often presents with features of heart failure. Our patient presented with atrial fibrillation. As the incidence of cardiac metastasis is quite rare, there is no standard established treatment. Certain chemotherapeutic drugs, such as 5-fluorouracil, oxaliplatin, irinotecan (FOLFIRINOX regimen), have been shown to improve cardiac metastases. Due to the extensive spread of primary cancer in our patient, she was planned for palliative chemotherapy; however, the patient expired before initiation of therapy.

Bedside Scoring System for Predicting Adverse Outcomes Among Patients Suffering From SARS-CoV-2 Infection.

Aim To develop a clinical risk score to predict adverse outcomes among diabetic hospitalized COVID-19 patients Methods The data was collected retrospectively from patients hospitalized with the SARS-CoV-2 virus at Sri Ramachandra Institute of Higher education and research. It integrated independent variables such as sex, age, glycemic status, socioeconomic status, and preexisting lung conditions. Each variable was assigned a value and the final score was calculated as a sum of all the variables. The final score was then compared with patient outcomes. The patients were scored from 0 to 8 and a score of 3 or more was considered as being at greater risk for developing complications. Number of mortalities in each group, any clinical deterioration requiring ICU admission, and the number of patients requiring a prolonged hospital stay of more than 10 days in each group were noted and the results compared. Results Higher blood glucose levels and preexisting lung conditions like chronic obstructive pulmonary disease (COPD), asthma, and pulmonary tuberculosis have been associated with a higher risk of developing complications related to SARS-CoV-2 illness. Of the 5023 patients enrolled in the study, 2402 had a score of 2 or below, and 2621 had a score of 3 or above. Among patients with a score of 2 or below 1.7% of the patients contracted a severe disease resulting in death. 2.9% were shifted to ICU, but recovered and 12.2% of patients had a prolonged hospital stay. Of those with a score of 3 or greater, 5.1% died, 7.36% were shifted to ICU, but recovered, and 19.5% required a prolonged hospital stay. The observed results were analyzed using the Chi-square test and were found to be significant at a p-level of 0.0001. Conclusion This clinical risk score has been built with routinely available data to help predict adverse outcomes in diabetic patients hospitalized with the SARS-CoV-2 virus. It is a good tool for resource-limited areas as it uses readily available data. It can also be used for other severe acute respiratory illnesses or influenza-like illnesses.

A Study of the Risk Factors and Urinary Podocin as an Early Prognostic Indicator of Renal Injury in Diabetic Nephropathy.

BACKGROUND: The development of diabetic nephropathy demands an early detection aiming to decrease the incidence of end stage renal incidence. Podocyte injury is an essential element in the diabetic renal disease occurrence and progression. We attempted to identify podocyte markers in the urine of patients with and without overt diabetic nephropathy, in comparison with controls to diagnose early podocyte injury. METHODS: The study included Type 2 Diabetic individuals with 45 of them having normoalbuminuria, 40 patients with microalbuminuria and 40 of them with macroalbuminuria (based on the albumin-creatinine ratio - ACR) and 45 non diabetic healthy controls from a medical college hospital from South India. Urinary podocin quantification was done among all these patients and compared among the different groups of study, along with other parameters. RESULTS: The fasting blood sugar, post prandial sugar, glycosylated haemoglobin, triglyceride levels and the duration of diabetes along with systolic and diastolic blood pressure, body mass index, all seemed to be strong risk factors for the diabetic kidney disease progression showing a significant correlation with microalbumin, glomerular filtration rate and urine albumin-creatinine ratio. Podocin was excreted in the urine at higher concentrations among patients with ACR less than 30, ACR 30-299 and ACR more than 300 compared to healthy controls respectively (p < 0.001). The glomerular filtration rate showed significant negative correlation with the levels of podocin excreted in urine whereas urinary podocin positively correlated with the fasting blood sugar, post prandial sugar, glycosylated haemoglobin, triglyceride levels and the duration of diabetes along with systolic and diastolic blood pressure, body mass index, microalbumin and urine albumin-creatinine ratio. CONCLUSION: The urinary podocin can serve as an early marker for diabetic nephropathy as well as a marker of disease progression and severity among the patients with Type 2 Diabetes. The standard risk factors have to be identified early and controlled inorder to slow down the progression of diabetic kidney disease.

Role of Cardiac Biomarkers in the Assessment of Acute Cerebrovascular Accident.

Background Stroke (cerebrovascular accident) has for long been a global burden in terms of its morbidity and mortality. Serum levels of cardiac enzymes such as creatine kinase-MB (CK-MB) component, troponin T, and brain natriuretic peptide have been found to be elevated among the patients with stroke and also serve to prognosticate these patients. The serum levels of these enzymes correlate directly to the severity of stroke in these patients. Objective Elevated cardiac enzymes among patients with acute cerebrovascular accidents are not uncommon despite the patients not having any cardiac problems. We aimed to identify the occurrence of elevated cardiac enzymes among patients with acute stroke and their correlation with the severity of stroke. Materials and Methods Our study included 100 patients of acute stroke with no previous history of cardiac ailments. Serum levels of troponin I and CK-MB were analyzed among these patients using enzyme-linked immunosorbent assay method within the first 2 hours of admission. Patients outcome during the hospital stay were analyzed. Stroke severity was assessed using the National Institute of Health Stroke score (NIHS score) and the modified Rankin Score (mRS). The cardiac enzyme levels were correlated with these scores. Results Twenty-eight percent of patients had elevated troponin I, while 72% patients had normal levels with the mean values of 10.36 to 106.54 ng/mL and 0.00 to 0.02 ng/mL, respectively. CK-MB levels were found elevated among 14% patients and normal among 86% patients with mean values of 5.8 to 124.36 and 0.0 to 4.3 ng/mL, respectively. Among the six patients who succumbed to death, three patients had increased troponin I and four had elevated CK-MB. NIHS scores of 21.0357±6.79 and 105.277±5.564 were seen in patients with elevated and normal troponin I, whereas NIHS scores of 20.4285±8.658 and 11.8721±9.273 were seen among patients with increased and normal CK-MB, respectively. The mRS scores were 4.3214±0.367, 2.4305±1.374, 4.2143±1.412, and 2.756±1.749 ng/mL among the patients with elevated and normal troponin I and CK-MB, respectively. Conclusion The mean values of cardiac enzymes troponin I and CK-MB were higher among patients with higher scores of NIHS and mRS. Among them, troponin I was very significant and it may serve as an early biomarker for the severity of stroke and hint on early cardiac evaluation among these patients.

Melioidosis presenting as septicaemia and facial nerve palsy.

A 43-year-old farmer presented with acute onset pneumonia, septicaemia and peripheral facial nerve palsy (left side). Burkholderia pseudomallei was isolated from the blood culture of the patient. The patient was successfully treated with intravenous meropenem and oral cotrimoxazole for 2 weeks followed by maintenance therapy with cotrimoxazole. The case is reported to increase awareness among the clinicians and microbiologists regarding melioidosis.

Prevalence, patterns, and factors associated with bleeding tendencies in dengue.

INTRODUCTION: The pattern of bleeding tendencies in dengue and its corellation with platelet count and other factors requires clarification. METHODOLOGY: A retrospective study on bleeding tendencies in adults with dengue and platelet counts of less than 100,000 per mm(3) was conducted. Factors associated with bleeding were analyzed. The study cohort were grouped as dengue with severe thrombocytopenia when platelet count was < 50,000/mm(3) and as dengue with moderate thrombocytopenia if platelet count was 50,000-100,000/mm(3) RESULTS: A total of 638 patients formed the study cohort. A 24.1% prevalence of bleeding tendencies was observed. Prior anti-platelet drug intake, platelet count of < 70,000/mm(3), international normalized ratio > 2.0, and partial thromboplastin time > 60 seconds were associated with bleeding. Esophagogastroduodenoscopy was found to identify structural gastroduodenal lesions when dengue was complicated by hematemesis or melena. CONCLUSIONS: The results of this study suggest that bleeding complications in dengue can occur at platelet counts of up to 70,000/mm(3), and that prior anti-platelet drug intake increases bleeding risk. Evaluation of hematemesis or melena in dengue with esophagogastroduodenoscopy is beneficial.