Lepra Reactions: Mimickers and Mirror to Unmask Complex Cases of Leprosy.

Leprosy is a silent disease with protean manifestations, especially during lepra reactions (LRs). Cases with atypical leprosy or LR simulate a number of conditions misdiagnosed frequently. Here, three classical cases of leprosy are reported for their complex presentation. Leprosy was hidden in Case 1 due to co-existing diabetes. COVID vaccination induced LR unmasked all leprosy lesions, which were extensive, large, bizarre and spreading to various immune zones. Case 2 presented with high-grade fever, tachycardia, generalized erythema and body aches. A detailed workup unveiled his leprosy with a rare presentation of Type 1 lepra reaction (T1LR) with erythroderma and severe systemic symptoms. Case 3 mimicked sarcoidosis and lupus erythematosus (LE) on routine workup. She had facial lesions in the malar area, photosensitivity, joint pains, raised angiotensin-converting enzyme (ACE) levels and positive anti-nuclear antibodies. Peri-appendageal granulomas on histopathology and therapeutic response to multidrug therapy helped in the early diagnosis of leprosy.

Enabling personalised disease diagnosis by combining a patient's time-specific gene expression profile with a biomedical knowledge base.

BACKGROUND: Recent developments in the domain of biomedical knowledge bases (KBs) open up new ways to exploit biomedical knowledge that is available in the form of KBs. Significant work has been done in the direction of biomedical KB creation and KB completion, specifically, those having gene-disease associations and other related entities. However, the use of such biomedical KBs in combination with patients' temporal clinical data still largely remains unexplored, but has the potential to immensely benefit medical diagnostic decision support systems. RESULTS: We propose two new algorithms, LOADDx and SCADDx, to combine a patient's gene expression data with gene-disease association and other related information available in the form of a KB, to assist personalized disease diagnosis. We have tested both of the algorithms on two KBs and on four real-world gene expression datasets of respiratory viral infection caused by Influenza-like viruses of 19 subtypes. We also compare the performance of proposed algorithms with that of five existing state-of-the-art machine learning algorithms (k-NN, Random Forest, XGBoost, Linear SVM, and SVM with RBF Kernel) using two validation approaches: LOOCV and a single internal validation set. Both SCADDx and LOADDx outperform the existing algorithms when evaluated with both validation approaches. SCADDx is able to detect infections with up to 100% accuracy in the cases of Datasets 2 and 3. Overall, SCADDx and LOADDx are able to detect an infection within 72 h of infection with 91.38% and 92.66% average accuracy respectively considering all four datasets, whereas XGBoost, which performed best among the existing machine learning algorithms, can detect the infection with only 86.43% accuracy on an average. CONCLUSIONS: We demonstrate how our novel idea of using the most and least differentially expressed genes in combination with a KB can enable identification of the diseases that a patient is most likely to have at a particular time, from a KB with thousands of diseases. Moreover, the proposed algorithms can provide a short ranked list of the most likely diseases for each patient along with their most affected genes, and other entities linked with them in the KB, which can support health care professionals in their decision-making.

Is tuberculosis epidemic riding upon the waves of COVID-19 pandemic? A time-trend study from South India.

Background: National Tuberculosis Elimination Programme (NTEP) activities have decelerated due to the COVID-19 pandemic. Doubt is raising globally on emerging tuberculosis (TB) epidemic related to COVID-19 pandemic. In this study, we aim to identify the trends in incidence and patterns of TB during the pandemic (2020-2022). Methods: A single-institution retrospective study was conducted. All data including demography, site of involvement, and the time trends of TB cases registered under NTEP between January 2019 and June 2022 at our hospital were retrieved from the prospective register. Statistical analysis was done using SPSS version 20.0. Results: Total 381 cases were registered. The mean age was 43 years (±17). The male: female ratio was 1.2:1. Majority of females (40%) and males (37%) were in the age of 11-30 years and 31-50 years, respectively. The TB cases' frequency in 2019, 2020, 2021, and 2022 (till June) were 38.3% (146), 11.8% (45), 29.4% (112), and 20.5% (78), respectively. The most common site involved was pulmonary (50%) followed by cervical lymph node (19.9%). A significant reduction in TB cases was noted in 2020 during the first wave of COVID-19. The estimated total TB cases in 2022 are similar to pre-COVID-19 year 2019. The ratio of pulmonary versus extrapulmonary TB was 1:1 during 2020. Conclusions: We found a significant reduction of TB cases during the first wave of COVID-19, but cases have started to rise again and yet to reach pre-COVID-19 status in 2022. No definite evidence of TB epidemic in the background of COVID-19 pandemic was found. Young females within 11-30 years were found to be more affected and need to be the main focus of TB preventive efforts. COVID-19 pandemic has affected the ratio between extrapulmonary and pulmonary TB significantly.

Association of Asthma With Patients Diagnosed With Metabolic Syndrome: A Cohort Study in a Tertiary Care Hospital.

Introduction Asthma is defined as a chronic inflammatory airway disease. The prevalence of both asthma and obesity has been rising simultaneously, demonstrating a parallel trend. Obesity is a significant factor in metabolic syndrome, and numerous studies have indicated a connection between metabolic syndrome and bronchial asthma. Aims and objectives The aim of this paper is to evaluate the association of asthma with patients diagnosed with metabolic syndrome. The main objectives were to analyze the clinical profile and spirometric indices in patients with metabolic syndrome and to assess asthmatic patients among them with spirometry and clinical parameters at a tertiary care hospital in Chennai. Materials and methods This hospital-based cohort study was conducted on 73 patients attending the outpatient department who had a known case of metabolic syndrome and were evaluated for asthma through history, physical examination, and a pulmonary function test. A history of cough, expectoration, shortness of breath, wheezing, chest tightness, allergy, seasonal variation, and smoking habits was asked, and a thorough physical examination was performed. Bronchial asthma was confirmed with airflow reversibility by spirometry as per the Global Initiative for Asthma Guidelines. Metabolic and spirometry parameters were examined, such as body mass index (BMI), waist circumference, waist-hip ratio, fasting blood sugar (FBS), postprandial blood sugar, hemoglobin A1C (HbA1C), serum insulin, lipid profile, C-reactive protein (CRP), forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and FEV1/FVC pre- and post-reversibility (baseline vs. six months). Results and discussion The average BMI of all participants was 29.6511 ±2.64564. The waist-hip ratio was 0.5512 ±0.43855, which decreased during the follow-ups, demonstrating a decline in the risk of obesity in study participants. The level of HbA1C showed a drop from 6.1% to 5.9% at the first follow-up. This exhibited a further reduction at the six-month follow-up in addition to a positive reflection in insulin sensitivity, indicating successful control of diabetes among study participants. It was discovered that this was statistically significant (p<0.001). At the third and sixth months of follow-up, the FEV1/FVC ratio increased by 38% and 37%, respectively, when metabolic syndrome was under control. The results show that controlling diabetes, hypertension, obesity, and triglyceride values improved asthmatic symptoms, and this was determined to be statistically significant (p<0.001). Conclusion The results of the current study demonstrated that the regulation and maintenance of metabolic parameters such as BMI, diabetes, hyperlipidemia, and hypertension aid in improving asthma control.

Comparative Analysis of Oxygen Saturation by Pulse Oximetry and Arterial Blood Gas in Hypoxemic Patients in a Tertiary Care Hospital.

INTRODUCTION:  Oxygen saturation is essential for medical care and is closely regulated within the body. Arterial blood gas (ABG) analysis is used to evaluate critically ill individuals' ventilation, oxygenation, acid-base status, and metabolic condition. Pulse oximetry is an easy and non-invasive way to measure the status of oxygen saturation non-invasively in clinical settings and provides a quick and precise assessment of oxygenation and reduces medical errors. SpO2 may not always be a reliable predictor of arterial oxygen saturation (SaO2), and hypoxemic, hemodynamically compromised, and critically ill patients may have lower SpO2 accuracy. A study is needed to assess and compare various oxygen saturation methods. AIMS AND OBJECTIVES:  The study aimed to compare the oxygen saturation levels measured by pulse oximetry and ABG analysis in hypoxemic patients. The objectives were to compare the values between SaO2, PaO2, and SpO2 values obtained from the patients, and correlate the study parameters among both techniques. MATERIALS AND METHODS: The study was conducted from February 2021 to June 2022 among the 102 hypoxemic patients who were admitted to the emergency and surgical intensive care unit (ICU) of Sree Balaji Medical College and Hospital in Chennai. Primary data on ABG analysis and pulse oximetry readings were collected from the study subjects. The patient and their past medical records, physical exam, chest x-ray findings, pulse oximetry, and ABG results were all reviewed. Each patient had their ABG, and pulse oximetry measured simultaneously. A comparison was made between SpO2 and partial pressure of oxygen (PaO2) and arterial oxygen saturation (SaO2) parameters using a paired t-test. The correlation was done against the SpO2 and ABG parameters and assessed for association using the correlation coefficient value; gender was also considered while correlating. RESULTS AND DISCUSSION: An observational study was done among 102 study samples to comparatively analyze the oxygen saturation by two methods, namely pulse oximetry and ABG, in hypoxemic patients. While comparing the mean values of SaO2 and SpO2, they were 84.41 ± 4.24 and 80.58 ± 5.77, respectively, and this difference was statistically very significant (p < 0.001). While comparing the mean values of PaO2 and SaO2, they were 61.02 ± 5.01 and 84.41 ± 4.24, respectively, and this difference was statistically significant (p = 0.043). While comparing the mean values of PaO2 and SpO2, they were 61.02 ± 5.01 and 80.58 ± 5.77, respectively, and this difference was statistically significant (p = 0.054). Among the study population, with regard to the correlation factor, there is notably a very high and strong positive correlation between SaO2 and SpO2 and between SpO2 and PaO2. There was a negative correlation between SpO2 and finger abnormalities and between SpO2 and blood pressure. CONCLUSION:  The ABG method is considered the gold standard. When SpO2 levels fall below 90%, pulse oximetry may not be accurate enough to reliably assess oxygenation. In such cases, where alveolar hypoventilation is suspected, it is recommended to complement pulse oximetry with ABG studies. This is because ABG analysis provides a more comprehensive assessment of oxygenation and acid-base status, which can aid in the diagnosis and management of respiratory conditions.

The Changing Trend of Syphilis: Is It a Sign of Impending Epidemic?

Background: Syphilis is a treatable bacterial infection caused by Treponema pallidum. There has been a change in incidence of syphilis in various nations over the years. Aim: To study the epidemiological trends, demographic profile, high-risk behaviour, clinical pattern, and stage of syphilis over the last ten years in patients presenting to an STD clinic in a tertiary care hospital. Material and Methods: This was a retrospective observational study over ten years. Records of all confirmed syphilis cases were analysed in relation to demography and clinical profile. Results: There were a total of 3,110 STD patients among whom 31 cases (accounting for 0.99%) of confirmed syphilis were seen. There was a significant increase in cases in the last five years of study, especially in the last year. An increase in primary (PS) and secondary syphilis (SS) was observed. Males outnumbered females (3:1). Mean age of patients was 35.0 ± 11.53 years. Professionals were most common (22.6%) having syphilis followed by farmers (19.35%). A significant proportion (45.1%) of our patients were at least graduates. Unprotected sex was seen in all the patients followed by extramarital/premarital sex (71.35%). There were 16.12% of cases who had a history of paid sex and 9.7% were homosexuals. SS and latent syphilis were more common (38.7% each) than PS (19.35%). In PS single chancre and in SS truncal asymptomatic rash was the commonest clinical presentation. Limitation: Single-centre study, including only self-reported patients leading to a small sample size, is the major limitation of the study. Conclusion: The increased trend of primary and secondary syphilis in recent years highlights that there is a risk of an impending epidemic.

Experience of Rituximab Therapy in Pemphigus: A Three-Year Retrospective Study from a Sub-Himalayan State.

Background: Pemphigus is a group of auto-immune blistering disorders, characterised clinically by mucocutaneous blisters and erosions and histopathologically by intra-epidermal acantholysis. It was traditionally associated with high morbidity and mortality. The use of rituximab has brought upon a new dawn in the treatment of pemphigus. Aim: A retrospective analysis to ascertain the efficacy, tolerance, adverse effect profile, remission, and relapse with the use of rituximab. Material and Methods: A retrospective analysis of all diagnosed pemphigus patients who received rituximab therapy over a period of 3 years was performed. The patient's baseline characteristics, disease duration, clinical presentations, mucosal involvement, disease-severity assessment, and adverse events with rituximab were noted. The outcomes were evaluated based on the definitions of the disease-outcome parameters as early and late endpoints. Results: Of the 17 pemphigus patients, there were 14 females (82.4%) and three males (17.6%) with a mean age of 35.9 ± 16.5 years (range: 9-65 years). Pemphigus vulgaris (PV) was the predominant type in 11 (64.7%) patients. After rituximab infusion, the 17 patients attained the end of consolidation phase (ECP) within 15 days to 3 months, and the mean duration was 1.24 months. The complete remission (CR on/off) ranged from 0.5 to 35 months, and the mean duration of remission was 21.7 months. Within a median time of 4.2 months, almost 80% patients achieved CR on therapy. Nine (53%) patients were in CR without any therapy till the end of the study period, and eight (47%) were in remission while on minimal therapy. Conclusion: Rituximab is an efficacious therapeutic agent for pemphigus and is better tolerated and safer to all the previous medications used in the treatment.

A Clinicoepidemiological Study of Psychiatric Co-Morbidity in Hansen's Disease.

INTRODUCTION: Leprosy is a chronic disease caused by mycobacterium leprae. Chronicity of the disease leads to various psychiatric co-morbidities, which are often undiagnosed and untreated. The main objectives of this study were to evaluate the frequency and nature of psychiatric co-morbidity in patients of Hansen's disease. MATERIALS AND METHODS: Seventy confirmed cases of Hansen's disease between the ages of 18 and 60 years attending the department of dermatology of Indira Gandhi Medical College and Hospital, Shimla were evaluated for various manifestations of Hansen's disease and screened for psychiatric co-morbidity using GHQ-12 and diagnosed using ICD-10 checklist. Severity of depression and anxiety was assessed with HAM-D and HAM-A scales, respectively. RESULTS: The prevalence of psychiatric co-morbidity was found in 27.14% of enrolled patients. Depression was most prevalent in (20%) mental disorder; followed by anxiety disorder (7.14%). Moderate depressive episode was the commonest seen in 11.42% patients whereas 5.71% patients had mild depression. Generalized anxiety disorder was seen in 1.42% whereas 5.71% patients had mixed anxiety disorder. Patients with higher education status, positive family history of leprosy, lepromatous leprosy, and hand deformities were significantly associated with higher psychiatric co-morbidity. CONCLUSION: Patients suffering from Hansen's disease have significantly high prevalence of psychiatric co-morbidity complicating the Hansen's disease. High index of suspicion is required to diagnose and treat it.

Post Herpetic Neuralgia: A Retrospective Study to Evaluate Response to Modified Jaipur Block with Increased Concentration of Dexamethasone.

BACKGROUND: Postherpetic neuralgia (PHN) is a complication of herpes zoster characterized by persistent dermatomal pain. It has a negative impact on the quality of life. There is no gold standard therapy for PHN, and various local and systemic treatments have been tried. There are studies reporting the use of combination of steroids and local anesthetics but there is no standardized method. AIM: To evaluate the response of modified Jaipur block with increased concentration of dexamethasone. METHODS: We conducted a retrospective study in patients who were given Jaipur block. The patients age, sex, duration of PHN, type and severity of pain were observed. A combination of 2% lignocaine and 0.5% bupivacaine and dexamethasone was injected subcutaneously. The pain was scored using visual analogue scale at the baseline, and 1 month after 1st, 2nd, and 3rd session of block and follow up after 6 months and 1 year. RESULTS: The mean age of our patient was 63.33 ± 9.5 years. The males outnumbered females. Thoracic dermatomes were more commonly involved. The mean duration of PHN was 11.58 ± 12.76 months; stimulus evoked PHN was the commonest type of pain seen. The mean visual analogue score (VAS) decreased progressively after each session of the block. Maximum patients (50%) had excellent response, whereas 1.9% did not respond to the block. Relapse of pain was seen in 5.6% of the patients. There was no significant side effect noted. LIMITATIONS: There was no objective method used to assess pain. CONCLUSION: PHN is chronic neuropathic pain. Response to modified Jaipur block is good, but if the duration of PHN is more, the recurrence rate is higher. Modified Jaipur block is an effective and safe treatment for PHN.

Leishmania donovani Infection with Atypical Cutaneous Manifestations, Himachal Pradesh, India, 2014-2018.

We conducted a molecular study of parasite sequences from a cohort of cutaneous leishmaniasis patients in Himachal Pradesh, India. Results revealed atypical cutaneous disease caused by Leishmania donovani parasites. L. donovani variants causing cutaneous manifestations in this region are different from those causing visceral leishmaniasis in northeastern India.

Spectrum of Cutaneous Adverse Drug Reactions to Anti-tubercular Drugs and Safe Therapy after Re-challenge - A Retrospective Study.

BACKGROUND: Tuberculosis (TB) is a major global health problem and leading cause of death. Anti-tubercular therapy (ATT) can lead to various adverse effects including cutaneous reactions. Re-challenge remains the only option to restart the safe therapy with limited number of most efficient primary ATT drugs. OBJECTIVES: To study the demographic profile, identify the spectrum of cutaneous eruptions, offending drug and the reinstitution of safe ATT. MATERIALS AND METHODS: This was a retrospective study with inclusion of the indoor patients with cutaneous adverse drug reaction secondary to ATT. Hospital records were analyzed regarding demographic characteristics, type of TB, ATT regimen, pattern of drug rash, offending drugs, laboratory parameters, and reinstitution of ATT after re-challenge. RESULTS: All the cases (40 patients) were reported in adults with male to female ratio of 1:1.2 and mean age of 50 years. Pulmonary TB was the most common type of TB observed in 24 (60%) patients followed by extra-pulmonary in 16 (40%) patients. Maculopapular rash was the most common (42.5%) type of cutaneous eruptions and ethambutol, the most common (45%) offending drug followed by other first line anti-tubercular drugs. Ten (25%) patients developed multiple drug hypersensitivity on re-challenging. Multiple drug hypersensitivity was seen in 10 (25%) patients. CONCLUSION: Drug reaction to ATT is like a double-edged sword as stopping ATT and starting treatment of reaction with systemic steroids can further aggravate the condition with increased risk of disseminated and multidrug resistant tuberculosis. Re-challenge with ATT not only find out the culprit drug but also helps to restart a safer alternate ATT regimen. LIMITATIONS: Small sample size, lack of proper hospital records due to which some patients were missed and the fact that re-challenge was not performred in mild lichenoid type rash.

A Rare Case of Extensive Pemphigus Vegetans.

Pemphigus vegetans is a rare variant of pemphigus vulgaris characterized by pustules and/or papillomatous vegetations, preferentially affecting intertriginous and periorificial areas. It has two subtypes: Hallopeau variant and Neumann variant. Cerebriform tongue, a morphology with typical pattern of sulci and gyri over dorsum of the tongue, is a well-known sign in pemphigus vegetans. We are presenting an unusual case of pemphigus vegetans with extensive involvement of mucosae, trunk, extremities including both extensors and flexural areas with verrucous paronychia and fissured tongue. During clinical exam we recognized multiple cutaneous vesicles, erosions and ulcers on mucosal sites. Clinical, histopathological, and direct and indirect immunofluorescence findings were compatible with pemphigus vegetans. Patient had completed her family so treated with intravenous dexamethasone-cyclophosphamide pulse (DCP) regimen with excellent response.

Lymphocutaneous Sporotrichosis of Face with Verrucous Lesions: A Case Report.

Sporotrichosis is a cutaneous mycosis caused by a dimorphic fungus, Sporothrix schenckii species complex clinically presenting as lymphocutaneous, fixed, or disseminated forms. A typical lesion is an erythematous papule, noduloulcerative lesion usually occurring at the site of penetrating trauma, mostly on the extremities. Verrucous lesion is an unusual presentation of sporotrichosis which can mimic the verrucous lesions seen in chromoblastomycosis, tuberculosis verruca cutis/lupus vulgaris (TBVC/LV), cutaneous leishmaniasis, and blastomycosis leading to diagnostic dilemma. Herein, we describe a case of facial verrucous sporotrichosis in a child from sub-Himalayan region.

A Study to Compare the Efficacy of Platelet-rich Plasma and Minoxidil Therapy for the Treatment of Androgenetic Alopecia.

BACKGROUND: Androgenetic alopecia (AGA) is the most common cause of hair loss in men with limited treatment options. Platelet-rich plasma (PRP) therapy is one of the newer treatment options in the management of AGA which has shown promising results. AIMS AND OBJECTIVES: This study was aimed at comparing the clinical efficacy of PRP therapy with minoxidil therapy. MATERIALS AND METHODS: In the study, patients were randomized into two groups - Group A (given PRP therapy) and Group B (given minoxidil therapy). Both groups were followed up over a period of 6 months, and final analysis was done with the help of global photography, hair pull test, standardized hair growth questionnaire, patient satisfaction score; in addition, a comparison of platelet counts in PRP was done, to know that if a clinical correlation exists between platelet concentration and clinical improvement. A total of 40 patients clinically diagnosed with AGA were enrolled in the study with 20 patients in each group. Four patients from Group A (PRP) and six patients from Group B (minoxidil) could not complete the treatment for 6 months and were eventually excluded. RESULTS: At the end of 6 months, 30 patients were evaluated to compare the efficacy of intradermal PRP and topical minoxidil therapy. On global photography, Group A (PRP) was found to have a comparatively better outcome than Group B (minoxidil). In hair pull test, hair growth questionnaire, and patient satisfaction score, Group A was found to be better than Group B. Mean platelet count at baseline was 3.07 ± 0.5 lac/mm, 3 while platelet count in final PRP prepared was 12.4 ± 1.7 lac/mm, and patients with a higher platelet count in PRP had a much better clinical improvement compared to patients with a low platelet count in PRP. Side effects with PRP therapy were minimal with better results which may improve the compliance of the patient. CONCLUSION: PRP therapy can be a valuable alternative to topical minoxidil therapy in the treatment of AGA.

A Rare Case of White Piedra Caused by Candida parapsilosis in the Sub-Himalayan Region of North India.

White piedra is a superficial fungal infection of the hair shaft, caused by Trichosporon, a noncandidal yeast characterized by the presence of numerous, discrete, asymptomatic nodules attached to the infected hair shafts. White piedra is considered a disease of tropical regions and occasionally reported from temperate countries. Although Candida parapsilosis such as Candida albicans is well known to cause cutaneous infections, it has been reported as a co-isolate for white piedra along with Trichosporon. We report a case of white piedra from a temperate region caused by C. parapsilosis.

Emergence of travel: Associated dengue fever in a non-endemic, hilly state.

BACKGROUND: We assessed the occurrence of dengue fever in association with travel in a non-endemic hilly region. The clinical presentation and laboratory parameters of febrile patients with a travel history to an endemic region were studied, and the role of the laboratory in the diagnosis was affirmed. MATERIALS AND METHODS: Febrile patients presenting with clinical features defining dengue with a history of travel to an endemic area constituted the study group. Serum samples were tested for dengue-specific NS1 antigen and IgM, IgG antibodies. The demographic data were retrieved from the hospital information system. A hematological and biochemical workup was done and the results analyzed using percentage, proportion, mean, and median. RESULTS: Out of 189 febrile patients, 58 were reactive to serological tests for dengue, with 47 (81%) males. The presenting features were chills and rigors, myalgia, cough, sweating, and vomiting. Thrombocytopenia (74.35%), lymphopenia (52.94%), and leucopenia (47.05%) were present in early disease, with AST >34 IU/L in 58.97% of the patients. The NS1 antigen was detectable between three and seven days of fever and the IgM antibodies after five days. The positivities to only NS1, both NS1 and IgM, and IgM alone were 60.34, 27.58, and 10.34%, respectively, and the median duration of fever was five, seven, and ten days, respectively. One case of dengue hemorrhagic fever and one of probable secondary dengue infection with detectable IgG were encountered. CONCLUSION: Dengue fever remains unsuspected in febrile cases in non-endemic regions. History of travel is an essential criterion to suspect dengue. A non-specific clinical presentation eludes diagnosis. Serological tests for antigen and antibodies, and hematological and biochemical markers are vital for distinguishing the diagnosis.