Immunoglobulin E (IgE)-Mediated Multiple Myeloma Presenting as Pleural Effusion.

Multiple myeloma (MM) is a disease characterized by the abnormal production of plasma cells. These plasma cells have the property to produce immunoglobulins (Ig), on the basis of which MM can be classified. Immunoglobulin G is responsible for most of the cases, while IgE mediates the rarest form of MM. Since the first case was reported in 1967, knowledge regarding IgE-mediated MM is based on individual case reports. Based on the information available, it is thought that IgE-mediated MM presents clinically with the involvement of renal, bone, and hematological symptoms, which are the same as any other myeloma. However, the MM rarely involves the pleura, leading to malignant pleural effusion. We present a case of IgE-mediated MM with a unique feature of pleural effusion. The patient presented with constitutional symptoms of MM, which were followed by lab investigations revealing low hemoglobin, hypercalcemia, and high creatinine levels. An incidental computed tomography angiography (CTA) revealed lytic lesions in the spine. This was followed by skull and chest X-rays as part of the workup to determine the extent of the disease. It revealed further lytic lesions in the skull, humerus, and scapula, along with pleural effusion. This led to the suspicion of MM, which was ultimately confirmed by serum protein electrophoresis and a bone marrow biopsy. The patient was started on a triple regimen of bortezomib, thalidomide, and dexamethasone, which led to substantial improvement in his symptoms.

Dengue and Hypokalemic Paralysis: A Rare Association.

Dengue is one of the most common mosquito-borne viral illnesses in tropical areas, including Pakistan. Presentation varies from a self-limiting flu-like illness to life-threatening conditions like hemorrhagic shock and multi-organ dysfunction leading to death. In the absence of vomiting and diarrhea, electrolyte abnormalities are rare findings. Though Guillain-Barré syndrome is a known association of viral illnesses presenting with flaccid paralysis, there is a possibility for dengue to cause hypokalemia without apparent gut or renal losses. Dengue-associated hypokalemic paralysis is an underrecognized entity but has a favorable outcome. The clinician should suspect this in patients presenting with motor weakness in dengue-endemic areas. Neurological complications of dengue are reported frequently now, so early recognition of these neurological manifestations is needed for the successful recovery of patients. Here, we discuss a case of dengue-induced hypokalemia presenting with acute flaccid paralysis.

Hypoplastic Myelodysplastic Syndrome: Symptom of Methotrexate Toxicity in Rheumatoid Arthritis.

Methotrexate is the conventional disease-modifying anti-rheumatic drug (DMARD) which is considered the drug of choice in the treatment of rheumatoid arthritis, but its prolonged use without monitoring leads to a number of complications involving different body systems. The toxic effects of long-term methotrexate (MTX) therapy mainly involve the liver, skin, gastrointestinal tract (GIT) and bone marrow. In the bone marrow, it mainly causes suppression of normal functionality, leading to the formation of abnormal blast cells and dysplasia. In this case report, we present a male patient with symptoms of hoarseness, fatigue and abnormal bleeding all of which can be affiliated with methotrexate-induced hypoplastic myelodysplasia. As pancytopenia can be a lethal complication of MTX toxicity, it is important to monitor the therapy and dosage of methotrexate so that in case of any unforeseen development of a complication vital steps may be taken to diagnose and treat it in time. Regarding our patient, after thorough history taking and undergoing extensive hematological workup, the diagnosis of MTX-induced hypoplastic myelodysplasia was made. His symptoms improved on withholding the drug methotrexate from his active regimen and adding folinic acid and colony-stimulating factors.

Variations In Spectrum Of Covid-19 Ct Findings And Its Severity Scoring In A Tertiary Care Hospital Of Bahawalpur, Southern Punjab Pakistan.

BACKGROUND: Recently the Coronavirus pandemic presented with different manifestations in different parts of the world, both on clinical examinations and on imaging. CT Scanning (CT Scan) chest is used for detailed evaluation of the different characteristic patterns determining the depth of disease. The study is aimed to assess the variations in spectrum of Covid-19 CT findings and relating severity (CT Severity Score) with the Clinical Symptoms in Bahawal Victoria Hospital, Bahawalpur. METHODS: In this cross-sectional study, patients referred to radiology department from outdoor for COVID screening were included from 1st May to 30th June 2020. Mean age range of patients was calculated, while presenting complaints and co-morbidities were tabulated in frequencies and percentages after analysis. Severity of symptoms and CT findings were correlated with biochemical and haematological tests. RESULTS: Patients' age range from 25 to 85 years with 62% males and 38% females. Statistically no significant difference was observed in CTSS on gender basis. As sensitivity of RT PCR is about 70%, negative cases cannot be considered disease free and this is seen in this study as CT findings suggestive of COVID are seen in these patients. Using 40-point CT-SS, 11 patients had a score of >19 with severe diseases, while 14 patients had common disease with a score range of 11-18 and 35 patients had <10 score with mild or no symptoms. CONCLUSIONS: In this study, a spectrum of patchy ground glass opacities, bilateral peripheral predominantly lower lung consolidations were observed. Quantitative analysis of inflammatory process as occurring in lungs in Coronavirus Disease 2019, using 40-point CTSS scoring on Imaging could provide a timely and objective approach towards identifying patients requiring intensive care and hospitalisation.

Variations In The Age Of Fusion Of Ischial Tuberosity; A Radiological Study.

BACKGROUND: Human skeleton develops from separate ossification centres which continue to ossify till the bone is completely formed. Radiological techniques are very reliable and useful method for estimating the age of individual for forensic and criminal reasons by observing these ossification centres. External inspection for age determination is liable to error. This study is thus aimed to assess the variation in age of fusion of ischial tuberosity in Pakistani population. METHODS: It was a cross sectional study, wherein data was retrospectively collected at Bahawalpur Victoria Hospital, a tertiary referral centre in which consecutively selected 47 females and 121 males between 10-24 years of age, attending the outpatient, referred from National Database and Registration Authority for the confirmation of age were selected. RESULTS: There were a total of 13 cases in stage I, 98 in stage II, 23 in stage III and 34 in stage IV. In stage II maximum numbers of cases were between the ages of 19-22 years whereas in stage IV the maximum numbers of cases were between 21-24 years of age. CONCLUSIONS: It is concluded that the earliest appearance of epiphyseal centre in males occurred at 12-13 years and in females at 10-11 years. While earliest complete union was seen at the age of 19-20 years in females and 16-17 years in males. All cases in age group of 23-24 years showed complete union.