Emergencies in Dermatology : Acute Skin Failure

Rational understanding of etiopathogenesis of the systemic complications arising out of sudden, severe alterations in structure and function of the skin consequent to the syndrome of acute skin failure clearly establishes the necessity of a dedicated ICU in a skin department. Immune suppression due to increased age, organ transplantation, malignancy, prolonged intake of steroids as also the indiscriminate use of drugs have lead to a spurt in the incidence of widespread, recalcitrant dermatoses with significant potential to eventuate into reaction patterns terminating into acute skin failure, viz. universal erythema and scaling of erythroderma and widespread denudations of bullous dermatoses. Prompt intensive management of all such cases in the ICU on the lines of 100% burns is mandatory.

Multidetector row computed tomography in bowel obstruction. Part 2. Large bowel obstruction

Large bowel obstruction may present as an emergency as high-grade colonic obstruction and can result in perforation. Perforated large bowel obstruction causes faecal peritonitis, which can result in high morbidity and mortality. Multidetector row computed tomography (MDCT) has the potential of providing an accurate diagnosis of large bowel obstruction. The rapid acquisition of images within one breath-hold reduces misregistration artefacts than can occur in critically ill or uncooperative patients. The following is a review of the various causes of large bowel obstruction with emphasis on important pathogenic factors, CT appearances and the use of multiplanar reformatted images in the diagnostic workup.

Multidetector row computed tomography in bowel obstruction. Part 1. Small bowel obstruction

Multidetector row computed tomography (MDCT) has the potential to provide high-resolution multiplanar imaging that can help in accurate diagnosis of small bowel obstruction. Reformatted multiplanar images can increase diagnostic confidence in identifying transition points causing obstruction and also allow accurate delineation of various pathological conditions. Accurate and early diagnosis of complications associated with small bowel obstruction can also help in the clinical management of patients. In appropriate clinical scenarios MDCT angiograms may also be performed. Furthermore the rapid acquisition of images within one breath-hold reduces misregistration artefacts than can occur in critically ill or uncooperative patients. The following is a review of common and unusual diseases causing small bowel obstruction as revealed on MDCT.

Short course of prednisolone in patients with solitary cysticercus granuloma: a double blind placebo controlled study

The study was conducted to confirm the role of a short course of oral corticosteroids in patients with solitary cysticercus granuloma with seizures by a double-blind placebo-controlled study. In an open-label trial we, in past, had demonstrated a beneficial role of prednisolone. A short course of prednisolone helped in early resolution of solitary cysticercus granuloma. In this double-blind placebo-controlled randomized study, 60 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either anti-epileptic monotherapy with prednisolone (n=30) or anti-epileptic monotherapy along with placebo (n=30). The patients received prednisolone, 1mg/kg/day for 10 days, followed by tapering over next 4 days. None of the patients received albendazole therapy. The patients were followed up monthly, at least for 9 months. A repeat CT scan was performed after 6 months. The data were analysed by chi-square test. The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 6 months demonstrated non-significantly better response for prednisolone treated patients. In prednisolone group the lesion disappeared in 52% of patients and in 48% patients who received placebo. However, a significantly lesser number of prednisolone treated patients (n=12%) than controls (n=48%), had seizure recurrence. Our study suggests that short-term prednisolone therapy may not help in rapid resolution of solitary cysticercus granuloma, however, prednisolone therapy improves seizure-related prognosis.

Telomere attrition and accumulation of senescent cells in cultured human endothelial cells

The human umbilical vein endothelial cell (HUVEC) is an important model of the human endothelium that is widely used in vascular research. HUVECs and the adult endothelium share many characteristics including progression into senescence as the cells age. Despite this, the shortening of telomeres and its relationship to the progression into senescence are poorly defined in HUVECs. In this study of several HUVEC lines we show notable consistency in their growth curves. There is a steady decline in the growth rate of HUVECs grown continually in culture and we estimate complete cessation of growth after approximately 70 population doublings. The HUVECs lose telomeric DNA at a consistent rate of 90 base pairs/population doubling and show a progressive accumulation of shortened telomeres (below 5 kilobases). This telomeric loss correlates with the accumulation of senescent HUVECs in culture as assessed by staining for beta-galactosidase activity at pH 6. Although the telomere length of a large population of cells is a relatively crude measure, we suggest that in HUVECs a mean telomere length (as measured by terminal restriction fragment length) of 5 kilobases is associated with entry into senescence. These data demonstrate the strong relationship between telomere attrition and cell senescence in HUVECs. They suggest that DNA damage and subsequent telomere attrition are likely to be key mechanisms driving the development of endothelial senescence in the pathogenesis of vascular disease.

Predictive value of routine hematological and biochemical parameters on 30-day fatality in acute stroke

OBJECTIVE

This prospective study was planned to study the prognostic value of routine clinical, hematological and biochemical parameters, including platelet aggregation in patients of acute stroke, on fatality occurring during the first 30 days.

MATERIAL AND METHODS

In this study 116 consecutive patients (77 males and 39 females) of stroke (within 72 hours of onset) were included. After clinical evaluation and neuroimaging, blood investigations, hemoglobin, total leukocyte count, platelet count, platelet aggregation, erythrocyte sedimentation rate (ESR), blood sugar, urea, creatinine, sodium, potassium, serum cholesterol, serum bilirubin, aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), albumin, and globulin estimations were performed. The patients were followed up for a maximum period of 30 days from the onset of stroke, and patients who expired were grouped as 'expired' and the rest as 'survivors'. Logistic regression analysis was carried out among the significant parameters to identify independent predictors of 30-day fatality.

RESULTS

Univariate analysis demonstrated that among hematological parameters, high total leukocyte count and ESR, at admission, correlated significantly with an undesirable outcome during the initial 30 days. Among biochemical parameters, elevated urea, creatinine, serum transaminases (SGOT and SGPT) and globulin levels correlated significantly with death. Logistic regression analysis demonstrated that a low Glasgow Coma Scale (GCS) score along with biochemical parameters such as high serum creatinine, SGPT, ESR and total leukocyte count correlated with death.

CONCLUSION

Impaired consciousness, high total leukocyte count, raised ESR, elevated creatinine and SGPT levels, estimated within 24 hours of hospitalization, are the most important indicators of 30-day mortality in patients with first-time ischemic stroke.

Focal nodular hyperplasia in a child with hemihypertrophy and multiple cutaneous vascular malformations

A case of focal nodular hyperplasia of the liver occurring in a 9-year-old girl with musculoskeletal hemihypertrophy and multiple cutaneous capillary haemangiomata is described. The child presented because of limb length discrepancy and was found to have a large mass in the liver. Imaging showed a mass of similar characteristics to normal liver tissue. Prominent vascular supply to the liver was also seen. We present this case to emphasize the important diagnosis of focal nodular hyperplasia, which may occur in syndromic form in children with typical cutaneous and skeletal manifestations.

Neurocysticercosis presenting as Weber's syndrome

This case report describes a rare, non-epileptic manifestation of neurocysticercosis where a 22-year-old male presented with acute onset right 3rd nerve palsy with left hemiplegia (Weber syndrome). Computerized tomography and magnetic resonance imaging revealed cysticercus granuloma. The patient improved and became asymptomatic with steroid treatment. Recognizing this clinical entity would avoid unnecessary antituberculous treatment and surgical intervention.

Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit?

AIM

The purpose of our study was to investigate whether reporting of plain chest radiographs affects immediate management of patients admitted to a medical assessment unit.

MATERIALS AND METHODS

During a 3 month period we prospectively evaluated 200 patients who had a plain chest radiograph on admission. After the post on-call ward round, an independent medical specialist registrar reviewed the notes, retrieving relevant clinical details. The plain chest films were reported independently by a trainee radiologist and consultant, reaching a consensus report.

RESULTS

There was 93% agreement between trainee and consultant radiologists (95% CI=89-96%). Seventy percent had documented reports by the on-call medical team. There was disagreement between radiology and medical reports in 49% of reported films (95% CI=40-57%). The radiologist's report led to a direct change in the immediate management of 22 patients (11%).

CONCLUSION

Only 70% of films had documented reports in the clinical notes despite this being a legal requirement. Radiology reporting does cause a direct change in patient management. Chest radiographs of patients admitted to a medical admissions unit should be reported by a radiologist with the minimum of delay.

Patient with limb girdle dystrophy presenting with dopa-responsive dystonia--a case report

Dopa-responsive dystonias are rare. We report a 14-year-old male who was diagnosed as a case of limb girdle dystrophy and had features suggestive of dopa-responsive dystonia.

Rheological microscopy: local mechanical properties from microrheology

We demonstrate how tracer microrheology methods can be extended to study submicron scale variations in the viscoelastic response of soft materials; in particular, a semidilute solution of lambda-DNA. The polymer concentration is depleted near the surfaces of the tracer particles, within a distance comparable to the polymer correlation length. The rheology of this microscopic layer alters the tracers' motion and can be precisely quantified using one- and two-point microrheology. Interestingly, we found this mechanically distinct layer to be twice as thick as the layer of depleted concentration, likely due to solvent drainage through the locally perturbed polymer structure.

Cauda-conus syndrome resulting from neurocysticercosis

A 60-year-old male, presented with insidious onset, gradually progressive, burning paresthesia over the saddle area, sphincteric disturbance, impotence and paraparesis. Investigations revealed a ring-enhancing lesion in the conus medullaris suggestive of neurocysticercosis. This was supported by quantitative enzyme-linked immunosorbant assay from purified cell fraction of taenia solium cysticerci. On treatment with steroids he showed marked improvement.

Neurofibromatosis: a diagnostic mimicker on CT in a known case of malignancy

A known case of early carcinoma cervix was found to have mediastinal widening on chest radiograph and hypoechoic oval retroperitoneal lesions on USG abdomen. CECT chest and abdomen showed these to be non enhancing lymph node like round to oval discrete mass lesions in mediastinum, abdomen and pelvis. With no other suggestion of carcinoma spread, local or distant and uncommon incidence of extensive lymphadenopathy in a early carcinoma cervix, biopsy from one of the representative lesion was performed which revealed it to be benign neurofibroma. Differentiation of these strategically located benign nerve sheath tumors from lymphadenopathy can sometimes be challenging on CT scan and in a known case of malignancy or with history of surgery for malignant neoplasm it may cause concern for disease spread or local tumor recurrence. Associated imaging and clinical features can sometimes be helpful in reaching the correct diagnosis.

Magnesium sulfate and neonatal outcomes of preterm neonates

OBJECTIVE

To determine whether in utero exposure to magnesium sulfate was associated with increased neonatal morbidity and mortality among premature neonates, and secondarily to determine the relationship, if any, between duration of magnesium sulfate exposure and neonatal morbidity and mortality.

METHODS

We studied 401 neonates at our institution who were born between 23 and 34 weeks' gestation following preterm labor or preterm premature rupture of membranes. The population was stratified by exposure to magnesium sulfate and compared by various neonatal outcome variables. Similarly, the magnesium-exposed population was stratified by duration of exposure and compared for various neonatal outcome variables. Student's t test, chi2 test, Fisher's exact test and logistic regression were used for analysis.

RESULTS

A total of 190 neonates were exposed to magnesium sulfate, while 211 neonates were not. The magnesium-exposed neonates were delivered at a significantly lower gestational age compared to the unexposed neonates (28.2 +/- 3.0 vs. 29.3 +/- 3.1 weeks, p = 0.001). Univariate analysis revealed no differences between groups with regard to rates of respiratory distress syndrome, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, patent ductus arteriosus, histological and clinical chorioamnionitis, neonatal sepsis or neonatal death. However, magnesium-exposed neonates were more likely to have received antibiotics (71.6% vs. 45.0%, p = 0.0001) and antenatal steroids (95.8% vs. 61.6%, p = 0.0001), factors known to affect perinatal morbidity and mortality. Controlling for antenatal confounding factors, magnesium sulfate use was not independently associated with neonatal mortality (odds ratio (OR) = 0.66; 95% confidence interval (CI) = 0.28, 1.54; p = 0.34). Seventy-nine neonates were exposed to magnesium sulfate therapy for more than 24 h, while 111 neonates were exposed for 24 h or less. There were no significant differences between groups with respect to neonatal outcomes, with the exception of an increased rate of clinical chorioamnionitis in the group exposed to magnesium for more than 24 h (22% vs. 8.2%, p = 0.005). After adjusting for gestational age at delivery, magnesium sulfate exposure for over 24 h was independently associated with a 2.8-fold increased rate of clinical chorioamnionitis (OR = 2.8, 95% CI = 1.14, 6.90; p = 0.02).

CONCLUSION

Prenatal exposure to magnesium sulfate was not associated with increased neonatal morbidity or mortality. However, prolonged exposure to magnesium sulfate may be associated with an increased risk of clinical chorioamnionitis.

Effect of weed extracts on seedling growth of some varieties of wheat

Allelopathic effect ofAvena fatua L., Cyperus rotundus L., Polygonum hydropiper L., and Solanum nigrum L. were examined on seedling growth of certain commonly used varieties of wheat (Triticum aestivum L.) in the Tarai region of U.P. state. The weed extracts inhibited the length of plumule in all the varieties (100%) with Solanum and it was in 12 (92%), 10 (77%) and 06 (46%) varieties with Polygonum, Avena and Cyperus, respectively. In radicle length, it was in 92% with both Polygonum and Solanum; and 85% and 69% of the varieties with Avena and Cyperus, respectively. However, all the four weed extracts reduced the dry weight of plumule, radicle and total seedling in all the varieties (100%) of wheat except in HD--2329 with Cyperus, in which it was positive. The percent reduction (percentage of control) was more than 50% in 92%, 77%, 54% and 39% of the varieties, respectively with Solanum, Polygonum, Avena and Cyperus. Among the weed extracts, the inhibitory effect on seedling growth in different varieties followed the order: Solanum > Polygonum > Avena and > Cyperus. On the basis of the present results, UP--2003 and WH--542 followed by PBW--226, Sangam and HD--248 were more susceptible to all the four weed extracts compared to the rest of the varieties of wheat.

Arthus reaction to recombinant hepatitis B virus vaccine

A severe, local, inflammatory, late-phase reaction accompanied by skin necrosis occurred after an infant was given an intramuscular injection of recombinant hepatitis B virus vaccine. The clinical course and appearance of the rash were typical of an Arthus reaction. Although not identical to this case, prior reported cases of complement-mediated reactions occurring after hepatitis B virus infection or vaccination provide theoretical support for this diagnosis.

Colonic wall necrosis due to tuberculosis in HIV-seropositive patient

We report a 40-year-old man with sloughing off of the colonic due to tuberculous associated with HIV infection. He presented with lump in the abdomen, distention and vomiting suggestive of intestinal obstruction. Proximal loop ileostomy with closure of colonic perforation was performed, with good recovery. This was followed by antitubercular chemotherapy.