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Infective endocarditis is an infection of the heart valves or endocardium caused by bacterial, viral, or fungal microorganisms. Blood cultures are used to detect the bacteria causing infective endocarditis, and echocardiography is performed to find the damaged heart valves. In blood culture-negative endocarditis, no endocarditis-causing organisms can be found in blood cultures, and blood cultures using usual laboratory methods remain sterile after inoculation of at least three independent blood samples. Case presentation: A 24-year-old male with a history of polysubstance abuse presented with complaints of fever, cough, and shortness of breath. He had a past history of pulmonary tuberculosis 4 years ago, for which he was treated with antitubercular therapy. High-resolution computed tomography of the chest revealed multiple cavitary lesions and consolidative areas in the bilateral lungs. Based on these findings, a provisional diagnosis of reactivation of pulmonary tuberculosis was considered, and antitubercular therapy was started. Due to his deteriorating condition, he was readmitted and evaluated. Bronchoalveolar lavage was done and sent for culture and sensitivity testing, which showed the presence of Staphylococcus aureus, and treatment was started accordingly. Despite continuing intravenous antibiotics for 5 days, the patient was not improving. Three sets of samples were withdrawn for blood culture and sensitivity testing, which came out to be negative. Transthoracic echocardiography was done, which revealed vegetation in the tricuspid valve. The patient was diagnosed with culture-negative tricuspid valve endocarditis based on the clinical criteria. Discussion: Blood culture-negative endocarditis is difficult to diagnose and presents challenges. When faced with a diagnosis like culture-negative endocarditis in the context of a condition that can appear very similar, like tuberculosis, a broad differential diagnostic approach is important. Conclusion: Intravenous drug use is the main cause of right-sided valvular infective endocarditis. Endocarditis should be considered in intravenous drug users even in the absence of positive blood cultures. An appropriate antibiotic regimen and long-term follow-up with a multidisciplinary team are necessary for a good outcome.
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Warfarin is the most commonly prescribed oral anticoagulant in Nepal. It is commonly used for chronic anticoagulation in patients with atrial fibrillation, venous thromboembolism, and artificial heart valves. The major side effect of warfarin is bleeding. Though extremely rare, a sublingual hematoma can lead to life-threatening complications as it can cause severe airway obstruction. We present a case of a 55-year-old female patient who had sublingual hematoma secondary to the use of Warfarin therapy. In addition to the discontinuation of warfarin, she was managed conservatively without any surgical intervention. Early diagnosis, timely discontinuation of the drug, and application of appropriate medical treatment are of utmost importance for reducing morbidity and mortality due to bleeding and airway compromise.
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Introduction: Sarcoidosis is a common, multisystemic non-caseating granulomatous disease of unknown etiology with cutaneous lesions present in about one-fourth of patients. Darier Roussy sarcoidosis is a rare variant of sarcoidosis with distinct cutaneous presentation characterized by multiple deep-seated nodules on the trunk and extremities which could either be asymptomatic or may present mild tenderness. Case presentation: A case of 35 yrs male with cough and fever for 3 months was initially diagnosed as a case of tubercular lymphadenitis and started with ATT following which ATT-associated cutaneous adverse drug reaction was suspected due to development of rashes with generalized redness and mild itching a few weeks after starting ATT. He then developed multiple, skin-colored, deep-seated, subcutaneous lesions over the legs then over the arms, forearms, thigh, and trunk. FNAC and histopathological examination of the lesions revealed non-caseating granulomas composed localized to the subcutaneous tissue. A diagnosis of subcutaneous sarcoidosis was made. Subsequently, steroid therapy was started. Discussion: Clinical manifestations of sarcoidosis range from asymptomatic (mostly) to progressive and relapsing disease. A family history of the disease raises the risk; those with one afflicted first-degree relative face a 3.7-fold increase in risk. Sarcoidosis is diagnosed based on three key criteria: a consistent clinical presentation, the discovery of non-necrotizing granulomatous inflammation in one or more tissue samples with confirmed histology, and the elimination of other origins of granulomatous disorders. . Diagnosis should be confirmed with a biopsy of the lesion, with the histological finding of non-caseating granuloma. Conclusion: Clinically localized subcutaneous sarcoidosis can be confused with ATT induced drug reaction due to the difficulties in diagnosing granulomatous skin disease. The prognosis is good with subcutaneous disease and if there are no disfiguring skin lesions or other critical organ involvement, corticosteroid therapy might suffice.
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Introduction: Corona viruses may also affect the central nervous system, inducing various neurological problems. Guillain-Barré Syndrome (GBS) is a rare immune-mediated post-infectious neuropathy typically leading to ascending weakness. Herein, we present a case of the patient to show an association of GBS and SARS-CoV-2 infection in Nepal. Case presentation: Twenty-seven yrs old man show an association of GBS and SARS-CoV-2 infection in Nepal who presented with difficulty in walking, backache, tingling sensations over the bilateral wrist and ankle, and features of facial nerve palsy. The diagnosis of GBS was made. Following Intravenous Immunoglobulin (IVIg) administration, the patient started showing motor recovery within a week. Clinical discussion: Patient who developed GBS as a likely post-infectious complication after the initial onset of infectious symptoms with persistent mild dry cough. Conclusion: GBS has severe complications and early diagnosis is important to monitor for loss of ambulation and initiation of immunoglobulin treatment. GBS should be considered as a potential rare but serious complication due to COVID-19.
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BACKGROUND: Chronic Obstructive Pulmonary Disease is a common, preventable, and treatable disease. Here, we conducted a systematic review of Chronic Obstructive Pulmonary Disease and its risk factors in Nepal for the last two decades. METHODS: We systematically searched databases to find all relevant Chronic Obstructive Pulmonary Disease research papers from 2000 to 2020. Two reviewers screened the literature using Covidence based on the study protocol. Data extraction was done using Microsoft Excel from selected studies. Final data analysis was done using CMA v.3. Our review protocol is available in PROSPERO (CRD42020215486) on 20 November 2020. RESULTS: The database search revealed 1416 studies of which 13 were included in quantitative analysis. The prevalence of Chronic Obstructive Pulmonary Disease in the adult population was 22·7% (CI, 12·5-37·7) of whom 54·9% were female (CI, 51·9-57·9). Nearly three-fourth of the participants (73·1%) of Chronic Obstructive Pulmonary Disease patients had informal education (CI, 58·6-84·0). The commonest primary occupation was agriculture and farming in 39·4% (CI, 31·3-48·2), followed by homemaker (36·8%). It was observed that 28·5% of the Chronic Obstructive Pulmonary Disease patients were former smokers, 25·8% non-smokers, and 59·4% were current smokers. More than two-third (76·2%) of Chronic Obstructive Pulmonary Disease patients relied upon traditional firewood cooking, whereas only 14.6% was adopted fireless cooking. CONCLUSIONS: The pooled prevalence of Chronic Obstructive Pulmonary Disease in Nepal was significantly high with more cases in females compared to males. Smoking and traditional firewood cooking were major risk factors among Chronic Obstructive Pulmonary Disease cases in Nepal.
