Guillain-barré syndrome without limb weakness: A rare variant with acute bulbar palsy.

A 76-year-old male was brought to the emergency room with an acute onset of breathlessness and difficulty swallowing. Examination revealed bilateral ptosis, bilateral vocal cord abductor palsy with diaphragmatic paralysis. He did not have any limb weakness. A diagnosis of acute bulbar palsy was made. Cerebrospinal fluid showed albumino-cytological dissociation. Magnetic resonance imaging of the brain (MRI) was normal, and a nerve conduction study (NCS) showed Acute Motor and Sensory Axonal Neuropathy (AMSAN). Guillain-Barré syndrome with acute bulbar palsy was considered. Here, we report a case of suspected Acute Bulbar Palsy plus (ABPp) syndrome. ABPp may be considered as a variant of GBS between the Miller-fisher and Pharyngeal-cervical-brachial variant and does not have any definite limb weakness. This patient also had ABPp with diaphragmatic palsy. However, whether this syndrome is an isolated variant of GBS or a continuum between the Miller-fisher syndrome (MFS) and Pharyngo-cervical brachial (PCB) variants remains to be elucidated. This case is relevant to primary care physicians as the disability with GBS remains high and may render a large burden to carers. The initial symptom of acute dysphagia must lead on the primary care physician to keep this disease in mind to prevent an unwarranted delay in diagnosis.

Primary pyogenic ventriculitis caused by Streptococcal pneumoniae in adults.

Primary pyogenic ventriculitis is more commonly manifested in children. Its presentation in adults due to Streptococcus pneumonia is rarely reported. It is mainly due to adequate vaccination cover and initiation of appropriate antibiotics. Ventriculitis is one of the complications of bacterial meningitis, requires long-term antibiotics and surgical intervention. Here, we are reporting a 67-year-old diabetic lady presented with a decrease in sensorium, seizure, and fever, diagnosed as bacterial ventriculitis. Her cerebro spinal fluid (CSF) picture suggestive of pyogenic meningitis, CSF, blood culture grew Streptoccous pneumoniae; MRI revealed -ventriculitis. She was treated with Injection Ceftriaxazone for 6 week duration. Serial MRI showed clearing of ventricular debris and she improved. This highlights the atypical presentation of pyogenic meningitis without nuchal rigidity, status epilepticus, and clinical improvement without the need of surgical intervention.

The level of knowledge and attitude on insulin therapy in patients with diabetes mellitus in a teaching hospital of Southern India.

AIM OF THE STUDY: To assess the level of knowledge and attitude on insulin therapy in patients with diabetes mellitus in a teaching hospital. OBJECTIVES: 1. To assess the level of knowledge and attitude on insulin therapy among patients with diabetes mellitus. 2. To find out the association between the knowledge and attitude on insulin therapy with the selected study variables. MATERIALS AND METHODS: This is a nonexperimental, cross-sectional study. A total of 100 participants were recruited from the outpatients and inpatients attending the department of general medicine and general surgery. Adult male and female with diabetes mellitus receiving insulin injection and willing to participate in the study were included in the study. The data was collected using 20 structured questionnaires to assess the level of knowledge and modified 4 point Likert scale was used, which contains 10 statements to assess the level of attitude on insulin therapy by interview method. RESULTS: It was observed from the results that the level of knowledge among the study participants was as follows: 4% of them had adequate knowledge, 44% had moderately adequate knowledge, and more than half (52%) of them had inadequate knowledge. The level of attitude among the study participants (27%) with diabetes mellitus had favorable attitude, more than half (69%) had moderately favorable attitude, and 4% had unfavorable attitude on insulin therapy. It is observed that there is no statistically significant correlation (r) =0.038, P = 0.707 between the level of knowledge and attitude on insulin therapy among patients with diabetes mellitus. CONCLUSION: This study showed that there was inadequate knowledge and unfavorable attitude among the diabetic patients regarding insulin therapy. The people with diabetes should receive ongoing need-based quality diabetic education by using innovative methods that is tailored to their needs, delivered by skilled healthcare providers.

Portal Venous Thrombosis-Disseminated Tuberculosis in Rheumatoid Arthritis.

Vascular thrombosis is one of the complications of tuberculosis. Deep vein thrombosis and pulmonary thrombosis have been reported with pulmonary and extrapulmonary tuberculosis. Splenic involvement in abdominal tuberculosis is among the rarest manifestations. Disseminated tuberculosis is predominantly reported in rheumatoid arthritis following ingestion of biological agents. Here, we report a case of disseminated tuberculosis in a rheumatoid arthritis patient who was on steroids and methotrexate for a long period, presenting with multiple splenic lesion and portal vein thrombosis, which was not reported earlier. She was treated with antitubercular drugs, anticoagulants and showed improvement.

Portal Venous Thrombosis: Eosinophilic Vasculitis.

Portal Vein Thrombosis (PVT) is caused by various thrombophilic states. PVT secondary to underlying vasculitis especially Churg-Strauss disease is among the rarest presentation. Here, we report a case of peripheral eosinophilia, eosinophilic ascitis and venous thrombosis involving portal vein and superior mesenteric vein diagnosed as Churg-Strauss Syndrome (CSS). He was managed with steroids and anticoagulants. Following initiation of steroids, eosinophilia and eosinophilic ascitis improved.

A case of primary amenorrhoea.

OBJECTIVE: To report a case of primary amenorrhoea and to describe an approach to evaluation. METHODS: Primary amenorrhoea can be due to diverse causes and needs detailed and astute evaluation. We report the case of a 17 years old individual born and brought up as a female, who was brought to us with primary amenorrhoea. Approach to such a patient with a review of available published literature is described. RESULTS: After detailed history, biochemical testing, imaging and karyotyping, we found that this patient had a XY karyotype with normal uterus, fallopian tubes and vagina, but streak gonads. CONCLUSION: Swyer syndrome (46,XY gonadal dysgenesis), a sex reversal disorder characterized by a phenotypic female with non-functional streak gonads, poorly developed secondary sexual characters, primary amenorrhoea and 46,XY karyotype was diagnosed. This patient was treated with gonadectomy and sex hormone replacement.

The role of urinary fractionated metanephrines in the diagnosis of phaeochromocytoma.

BACKGROUND & OBJECTIVES: Plasma and urinary metanephrines are used as screening tests for the diagnosis of phaeochromocytoma. The recommended cut-off levels are not standardized. This study was conducted to identify a cut-off level for 24 h urinary fractionated metanephrines viz. metanephrine (uMN) and normetanephrine (uNMN) using enzyme immunoassay for the diagnosis of phaeochromocytoma. METHODS: Consecutive patients suspected to have phaeochromocytoma were included in the study. uMN and uNMN in 24 h urinary sample were measured using a commercial ELISA kit. RESULTS: Overall, 72 patients were included over a period of 18 months. Twenty patients had histopathologically confirmed phaeochromocytoma and in 52 patients phaeochromocytoma was ruled out. Using the upper limit of normal stated by the assay manufacturer as the cut-off, uMN >350 µg/day had a low sensitivity and uNMN >600 µg/day had a poor specificity. By increasing the cut-off value of uNMN to twice the upper limit, specificity increased significantly without much loss in sensitivity. Combining uMN and uNMN using a cut-off twice the upper limit improved the diagnostic performance - sensitivity (95%); specificity (92.3%); positive predictive value (PPV - 82.6%); negative predictive value (NPV - 98%). In subsets of patients with a variable pretest probability for phaeochromocytoma, the PPV correlates well with the occurred of these tumors decreased, while the NPV remained at 100 per cent. INTERPRETATION & CONCLUSIONS: ELISA is a simple and reliable method for measuring uMN and uNMN. The test has a good NPV and can be used as an initial screening test for ruling out phaeochromocytoma. Each hospital will have to define the cut-off value for the assay being used, choosing a proper control population.