Brain Calcifications Secondary to Idiopathic Hyperthyroidism and Hypoparathyroidism.

Background: Thyroid and parathyroid hormones are essential components of the metabolic system and its regulation. Concurrent hyperthyroidism with hypoparathyroidism is an extremely rare finding and is not considered a common etiology of brain calcifications seen on imaging. Brain calcifications can cause a range of neurologic symptoms, including movement disorders, cognitive impairment, and seizures. Prompt recognition and treatment of hypoparathyroidism are essential to prevent or minimize the development of brain calcifications and associated neurologic symptoms. Case Report: A 39-year-old female presented to the emergency department in an unconscious state with generalized weakness and tonic-clonic seizures for 1 day. On clinical examination, she had jerky movements of her upper limbs, and her Glasgow Coma Scale score was 4/15. Supporting hypoparathyroidism, she had low levels of serum parathyroid hormone, calcium, and vitamin D and a high level of serum phosphorus. Her magnesium level was normal. Thyroid profile revealed hyperthyroidism. Noncontrast-enhanced computed tomography scan at the midbrain level showed multiple bilateral hyperintense areas in the basal ganglia and thalami suggestive of calcifications. The patient was treated with calcium and vitamin D supplements and antithyroid agents that successfully resolved her symptoms. Conclusion: This case provides important documentation for including hypocalcemia as a result of hypoparathyroidism in the differential diagnosis of patients with seizures. The treatment approach used with our patient can be considered for managing seizures in cases where the underlying cause is challenging to identify. This case highlights the importance of a thorough evaluation and individualized treatment plan for patients with seizures.

Real-World Evidence to Evaluate the Efficacy and Safety of Vonoprazan in Gastrointestinal Disorders in the Pakistani Population.

BACKGROUND AND AIM: While proton pump inhibitor (PPI) therapy has proven to be effective in managing gastroesophageal reflux disease (GERD), a notable portion of patients who experience GERD symptoms may not respond to this treatment. Research suggests that roughly 30% of individuals with a presumed GERD diagnosis may continue to experience symptoms, whether partially or completely, even when receiving PPI therapy. The aim of this study was to assess the treatment of gastrointestinal diseases with a novel potassium-competitive acid blocker (P-CAB), vonoprazan, in terms of its effectiveness and safety in the Pakistani population. METHODS: This prospective, multicenter, observational study was conducted in Pakistan. This study included 1,642 patients from January 2023 to August 2023, aged 18 years, with gastrointestinal disorders. All demographic data, medical history, GERD severity assessment questionnaire (GerdQ), and laboratory parameters, including stool assessment for Helicobacter pylori (H. pylori), were observed. Patients were orally treated with vonoprazan at doses of 10 mg or 20 mg, once or twice daily. Statistical analysis was done by one-way ANOVA. RESULTS: Out of 1,642 patients, 840 (51.2%) were males and 802 (48.8%) were females, with a mean age of 39.81±14.61 years. The mean GerdQ score at baseline was 20.37±15.87, 7.24±8.15 at the second week of treatment, and 3.70±6.31 at the fourth week of treatment (p<0.001). 90.74% of patients achieved H. pylori eradication. Most patients were acid regurgitation and heartburn-free for >70% of days. Most of the patients, 1,283 (78.13%), exhibited good treatment compliance. Mild adverse events were reported in 37 (2.3%) patients. CONCLUSIONS: The use of vonoprazan significantly reduced the likelihood of GERD by improving symptoms and was also highly effective in the elimination of H. pylori infections. Vonoprazan was generally well tolerated.

Asymptomatic Dandy Walker Malformation In An Elderly Male With Acute Haemorrhagic Stroke - A Case Report.

Dandy-Walker Malformation (DWM) is a rare congenital anomaly of the posterior cranial fossa. Features of DWM include hypoplasia of the cerebellar vermis, enlargement of the posterior fossa, and cystic dilatation of the fourth ventricle. MRI is the modality to confirm the diagnosis. Treatment is usually symptomatic and required when signs of hydrocephalus develop. Rare cases of asymptomatic DWM diagnosed incidentally are reported in literature. We report a case of DWM in a 60-year-old male who presented with haemorrhagic stroke and was later found to have DWM on brain imaging.

Correction: Real-World Evidence to Evaluate the Efficacy and Safety of Vonoprazan in Gastrointestinal Disorders in the Pakistani Population.

[This corrects the article DOI: 10.7759/cureus.48994.].

Termination of seizures in the paediatric age group, best benzodiazepine and route of administration: A network meta-analysis.

This network meta-analysis aims to compare various benzodiazepines and their route of administration using the data published exclusively in randomized controlled trials (RCTs). Two thousand two hundred sixty-three children presenting with an episode of seizure to ER or to a paramedic where they were administered a benzodiazepine as the first-line treatment were included. All the outcomes were measured for their mean with 95% CI and rank probability. The primary outcome was the number of successful seizure cessation. Secondary outcomes were the time interval between drug administration and seizure cessation, the time interval between patient arrival and seizure cessation and the number of episodes of seizure recurrence after drug administration. For the number of successful cessations, intramuscular midazolam showed the highest mean and best rank probability with a value of .881 (.065) and 57.9%, respectively. For the time of cessation, both intravenous lorazepam (IVL) and intravenous diazepam showed a mean of 3.30 (1.30) with IVL having the highest rank probability of 32%. For total time for cessation, intranasal midazolam showed the best mean and rank probability with a value of 4.3 (1.1) and 55%, respectively. Buccal midazolam showed the lowest mean with a value of .106 (.084) for rate of recurrence. Although there was no significant difference between the treatments, but based on the rank probability, IVL shows more promising results for patients who already have an established intravenous line, and for patients presenting in the ER without an intravenous line, the first line of treatment should be INM as it shows the highest rank probability in total time with second-highest successful cessation rate.

A Case Report of Behcet's Disease With Thromboses in the Superior Vena Cava and External Iliac Vein.

Behcet's disease (BD), also known as Behcet's syndrome, is a rare, chronic, autoimmune disorder of unknown origin. Its manifestations are thought to be caused by vasculitis, resulting in damage to blood vessels of all sizes throughout the body. We report a 25-year-old Pakistani male who is sexually active and presents with a one-year history of shortness of breath, cough, exertional dyspnea, and neck and facial swelling. On examination, he had severe anemia, mouth ulcers, distended neck and chest veins, prominent abdominal veins, and a scrotal ulcer. After going through mandatory investigations to evaluate the presenting signs and symptoms, thromboses were found in the major veins, including the superior vena cava (SVC) and external iliac vein, as well as a positive pathergy test. Accordingly, a diagnosis of Behcet's disease with cardiomyopathy and venous thrombosis was made. He was treated with anticoagulants, steroids, and azathioprine for six months and subsequently went into remission.

Unusual Initial Presentation Of Primary Antiphospholipid Syndrome As Postpartum Symmetrical Peripheral Gangrene.

BACKGROUND: Antiphospholipid syndrome (APS) is an acquired prothrombic state with recurring thromboembolic and obstetric complications in the presence of antiphospholipid antibodies. Isolated skin manifestation especially symmetrical peripheral gangrene (SPG) in postpartum phase is reported rarely. To highlight this unusual presentation of APS with SPG we present a case of young female who developed SPG on her third postpartum day. Postpartum period runs a high risk of sepsis but development of such extensive and rapid ischemic changes in APS is seen uncommonly.

Electrocardiographic Abnormalities in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

OBJECTIVE: The objective of this article was to determine the frequency of different electrocardiographic (ECG) abnormalities in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: This is a cross-sectional study. PLACE AND DURATION: The study was conducted at the medicine department at Civil Hospital Karachi, Pakistan, between November 2018 and May 2019. METHOD:  Both female and male participants aged 18-60 years with acute exacerbation of COPD (as per the operational definition) for more than three days who did not receive any treatment for exacerbation were included in the study. Twelve-lead ECG was recorded (Schiller AG, Baar, Switzerland) for 10 minutes after the supine rest, with a 50 mm/s of paper speed, 10 mm/mV of gain, and filter default settings. RESULTS:  In total, 140 participants (male: n = 124 [88.6%] and female: n = 16 [11.4%]) were included the research. The mean age of the participants was 40.43 ± 11.51 years. In terms of severity, 46 (32.95) patients presented with mild, 46 (32.9%) with moderate, and 48 (34.4%) with severe exacerbation. Moreover, 33 (23.65%) participants had ECG abnormalities, i.e., 13 (9.3%) patients presented with right atrial enlargement, and eight (5.7%) with right ventricular hypertrophy. Patients with a longer smoking duration (years) were likely to present with ECG abnormalities. CONCLUSION:  Patients with COPD who had severe acute exacerbation and a long smoking duration have a high prevalence of ECG abnormalities. Hence, ECG may be a valuable tool for detecting ischemic abnormalities among patients with COPD, independent of previously known heart disease, in clinical settings.

A Rare Presentation of Brucellosis as Myocarditis.

Brucellosis is commonly transmitted by consumption of unpasteurized dairy products and most commonly presents as fever, arthralgia, fatigue, hepatosplenomegaly, and peripheral arthritis. Our patient presented with a history of three months of high-grade fever, undocumented significant weight loss, jaundice, and hepatosplenomegaly. On the seventh day of admission, he developed sudden onset of shortness of breath, and his jugular venous pressure was raised with fine crackles at the lung bases bilaterally and pedal edema up to the ankles bilaterally. Electrocardiography was done, which showed T wave inversions in 1 and augmented Vector Left (aVL). Troponin I was raised at that time, and echocardiography revealed an ejection fraction of 40%. A diagnosis of myocarditis secondary to brucellosis was made.

GeneXpert in stool: Diagnostic yield in Intestinal Tuberculosis.

BACKGROUND: Diagnosing intestinal (Luminal) tuberculosis is challenging due to limited yield of diagnostic modalities like CT scan, colonoscopy with blind ileal biopsies. GeneXpert MTB/RIF (Xpert) assays for diagnosing tuberculosis have been performed in the body secretions with excellent results. Its yield in stool is tested in this study. OBJECTIVE: The study aims to evaluate the yield of GeneXpert assay in stool of suspected cases of intestinal tuberculosis. METHODS: Hundred patients with suspected intestinal tuberculosis underwent routine biochemical tests, radiological investigations, colonoscopy with caecal and blind ileal biopsies for histopathology. Fresh stool samples were collected, processed for DNA extraction, tested using 2:1 ratio of GeneXpert reagent to sample to give positive or negative results for Mycobacterium tuberculosis and Rifampicin resistance. RESULTS: Out of hundred participants, 52% were female. Mean age was 28.21 ± 12.13. CT scan and colonoscopy findings suggestive of TB were present in 47% and 43% participants respectively. GeneXpert in stool was positive in 20% cases. Considering mucosal biopsy with histopathology of intestinal specimens as diagnostic of abdominal Tuberculosis, sensitivity and specificity of GeneXpert was 39.1% and 85.7% respectively. CONCLUSION: Stool GeneXpert assay offers an alternative approach to detect intestinal tuberculosis rapidly with good diagnostic accuracy. Although it cannot replace the AFB culture and histopathology but contribute for early diagnosis and management.

Neuromyelitis Optica (NMO) with Abdominal Tuberculosis (TB).

Neuromyelitis Optica (NMO), previously regarded as a form of multiple sclerosis, is defined by Gault and Devic, as a retrobulbar neuritis or papillitis accompanied by acute myelitis and occasionally other neurological symptom or signs not restricted to the spinal cord or optic nerves. With the diagnosis of specific antibodies, probable role of humoral immunity supports its pathogenesis. Only a few cases of NMO have been reported in association with pulmonary tuberculosis (TB). Here we report a case of young girl with acute onset paraplegia diagnosed to have NMO, who later on during hospital stay developed ascites which cultured positive for Mycobacterium tuberculosis. This association of abdominal TB with NMO is under-reported in literature.

Amyloidosis with Multiple Myeloma Presenting with Acromegalic Features.

Amyloidosis and multiple myeloma are included in the same spectrum of clonal plasma cell disorders. Amyloidosis can present with localized deposits or manifest as systemic disease involving multiple organs. Here we are reporting a case of an elderly female, having amyloidosis leading to facial disfigurement and neuropathy for many years and then presenting with concomitant multiple myeloma as an incidental diagnosis with no typical symptoms related to it at all.

Frequency, characteristics and risk factors of carotid artery stenosis in ischaemic stroke patients at Civil Hospital Karachi.

OBJECTIVE: To determine the frequency and characteristics of carotid artery stenosis in acute ischaemic stroke patients and to assess the significance of common risk factors for carotid stenosis in these patients. METHOD: One hundred consecutive patients admitted with acute ischaemic stroke were included in the study. The relevant history, physical examination and laboratory investigations were done as per the Performa. Doppler ultrasound was performed during the hospitalization to find out carotid artery stenosis. Statistics analysis was done with SPSS v 14. RESULTS: Out of one hundred (100) patients, sixty one (61%) were males and thirty nine (39%) were females. Thirty nine patients (39%) were found to have carotid artery stenosis, all of them on the ipsilateral side corresponding to the ischaemic lesion. Eleven (11) of these patients had stenosis on the contra lateral side as well. The presence of stenosis was significantly correlated with older age and the presence of multiple risk factors. Majority (52%) of the lesions were severe to critical as determined by Doppler peak systolic velocity. Fifty nine (59%) were non calcified. CONCLUSION: Carotid artery stenosis is strongly associated with ischaemic stroke. Doppler studies are recommended for the high risk patients for the primary as well as secondary prevention of ischaemic stroke.

Vitamin D deficiency in fibromyalgia.

OBJECTIVE: To check the Vitamin D levels in patients diagnosed as fibromyagia in our population. METHODS: Study was done at Medical OPD of Civil Hospital Karachi, from January to March 2009. Female patients diagnosed as Fibromyalgia according to American College of Rheumatology (ACR) criteria and exclusion of systemic illness on examination, and normal reports of blood CP, ESR, serum calcium, phosphate and Alkaline Phosphatase, were asked to get Vitamin D levels in their serum. Vitamin D deficiency is defined as <20 ng/ml, Vitamin D insufficiency 21-29 ng/ml and Vitamin D sufficiency equal or >30 ng/ml. RESULT: Forty female patients were included in the study. The mean age was 37.65 +/- 11.5 years. Mean Vitamin D level was 17.41 +/- 5.497 ng/ml. Thirty two (80%) of patients had Vitamin D deficiency, mean levels of 15.855 +/- 4.918 ng/ml and 8(20%) had Vitamin D insufficiency, mean levels of 23.64 +/- 2.39 ng/ml. Patients with vitamin D deficiency and age less than 45 years were 22 (68.75%), had mean vitamin D level 16.87 +/- 4.48 ng/ml whereas in age ranging from 46-75 years were 10 (31.25%) had mean vitamin D level 16.09 +/- 6.45 ng/ml. CONCLUSION: Vitamin D deficiency is frequently seen in patients diagnosed as fibromyalgia and nonspecific musculoskeletal pain in our population. Although the sample size of the study is small, but the figures are so alarming that it is an eye opener towards the need of a population based study, including normal population as well as those presenting with musculoskeletal pain.

Acute acalculous cholecystitis in dengue fever.

OBJECTIVE: To investigate the frequency, clinical features, management and outcome of acute acalculous cholecystitis in dengue fever patients. METHODS: Forty patients were admitted with the diagnosis of dengue fever, according to the clinical manifestations and laboratory investigations. The diagnosis of dengue fever was confirmed by a positive IgM antibody test result for a late or convalescent phase blood specimen. The diagnosis of acute acalculous cholecystitis was made according to clinical features and sonographic findings. Liver function tests, complete blood counts were determined. Abdominal ultrasound was performed with a real time scanner in patients with abdominal pain and abnormal results on liver function tests. RESULTS: Eleven out of 40 patients of dengue fever (27.5%) had complication of acute acalculous cholecystitis. There were 8 males and 3 females. The mean and standard deviation from the onset of fever to hospital visit was 3.3 +/- 0.8 days (range 2-5 days). The mean white cell counts was 4154 +/- 1577.5 cmm. The mean platelet counts were 26,727 +/- 10460.3 cmm on presentation in hospital. The mean SGPT level was 148.5 +/- 190.17 mg/dl. Mean alkaline phosphatase was 398 +/- 214.8 mg/dl. On sonography all had thickened gall bladder. The mean gall bladder wall thickness was 5.2 +/- 1.3 mm. Three patients had ascites and one patient had pleural effusion. CONCLUSION: Acute acalculous cholecystitis was seen in a significant proportion of patients with dengue fever. All patients improved with good hydration and correction of thrombocytopenia. Based on these observations it is suggested that close observation and initial treatment of thrombocytopenia is mandatory.

Three consecutive audits to achieve acceptable colonoscopy completion rates.

OBJECTIVE: To compare the acceptable colonoscopy completion rates in three successive audits, identifying the reasons for failure of completion and rectifying them to improve the performance at our endoscopy unit. METHODS: Study was conducted at Endoscopy unit of Medical Unit One Civil Hospital Karachi. The first audit was conducted retrospectively on the colonoscopy results, done from November 2004 to November 2005. As the information was incomplete, a performa was designed for the next prospective audit from December 2005 to November 2006. The shortcomings found in the results of this audit were improved in the third audit done prospectively from December 2006 to November 2007. RESULTS: In the first audit 164 patients (111 male) underwent colonoscopy. The mean age was 40 +/- 10.08 years. The overall caecal intubation rate was 55%, but adjusted caecal intubation was not calculated because of inadequate documentation. In the second audit, 119 patients (66 male) underwent colonoscopy. The mean age was 45 +/- 10.17 years. After implementing changes the overall crude caecal intubation rate was 54.8% and the adjusted caecal intubation rate was 75% with exclusion of strictures and poor preparation. In the third audit, 122 patients (58 males) underwent colonoscopy. The mean age was 38 +/- 11.07 years. With further improvement in methodology the overall crude caecal intubation rate was (80.3%) and the adjusted caecal intubation rate was (98%). CONCLUSION: These audits allowed us to evaluate our endoscopy services and to detect the short comings and deviation from standard techniques and hence improving the performance in the subsequent year for the benefit of patients.

Liver histology in hepatitis C virus positive patients with normal and elevated alanine amino transferase levels.

OBJECTIVE: To compare liver histology in HCV RNA positive patients with normal and elevated Alanine Aminotransferase Level (AST). METHODS: This Cohort (prospective) study was conducted at Civil Hospital Karachi from Jan 2007 to July 2007. Forty patients with positive HCV RNA were included. Their liver function tests were followed for three months. Those having normal ALT on three occasions were taken as controls and those having elevated ALT were taken as cases. Liver biopsy was performed, Specimens were reviewed by single pathologist. Scheuer's scoring for grading of inflammation and staging of fibrosis of chronic hepatitis was used. RESULTS: Out of Forty patients having positive HCV RNA, 14 (35%) were male and 26 (65%) were female. Mean ALT in control group was 27.3 +/- 6.1 u/l, mean ALT in cases was 91.7 +/- 39.95 u/l. Mean age in controls was 34.2 +/- 10.75 years and in cases was 33.6 +/- 9.40 years. On histopathology, the mean grade of inflammation in controls was 1.40 +/- 0.681 while in cases was 1.20 +/- 0.834, which was not statistically significantly different in the two groups (p = 0.411). Similarly mean staging of fibrosis in controls was 1.20 +/- 0.768 and in cases was 1.35 +/- 1.348 which was also not statistically different in the two groups (p = 0.668). Stage 3 and 4 fibrosis was seen only in raised ALT group and not in the controls. CONCLUSION: Patients with persistently normal ALT and elevated ALT, although had similar grading of inflammation but the fibrosis score was more in elevated ALT group. None of the patients with normal ALT had normal histology, so decision for antiviral treatment should be individualized in this group also.