Clinicohistological Profile of Cutaneous Tuberculosis in Central Nepal

BACKGROUND

There are few studies on cutaneous tuberculosis in Nepal.

OBJECTIVE

To analyse the epidemiological, clinical and histological patterns of cutaneous TB over the past 5 years.

METHOD

Patients with cutaneous tuberculosis diagnosed from January 2010 to December 2014 at College of Medical Sciences, Chitwan, Nepal were included in the study. Chest radiography, routine investigations and screening for HIV was performed in all cases.

RESULT

A total of 47 clinical cases of cutaneous tuberculosis were diagnosed. The most commonly affected age group was 41-50 years. Male to female ratio was 1.5:1. Duration of cutaneous tuberculosis ranged from 1 month to 33 years. Lupus vulgaris was the most common clinical type (64%), followed by tuberculosis verrucosa cutis (19%). Two cases (4%) were diagnosed as papulonecrotic tuberculid. Overall, the most common site of involvement was extremities (55%) followed by head and neck, trunk, and perianal region. Histopathologic features of epitheloid cell granuloma with Langhans type giant cells were seen in 89% of cases, and in remaining 11% cases, chronic inflammatory dermatitis and nonspecific chronic dermatitis were observed.

CONCLUSION

M Tuberculosis is endemic in Nepal and the incidence of cutaneous tuberculosis at our centre was 0.1%. Lupus vulgaris was the most common type followed by tuberculosis verrucosa cutis in our study. Cutaneous tuberculosis can be accompanied by tuberculosis in internal organs and hence should be looked for. Clinicopathologic correlation is necessary to make a proper diagnosis.

Intravenous Iron Sucrose Therapy in Iron Deficiency Anemia in Antenatal and Postnatal Patients

INTRODUCTION

Dermatophytosis is a common superficial fungal infection of the skin, hair and nails caused by Trichophyton, Microsporum and Epidermophyton dermatophytic species. Identification of causative dermatophytic species tend to vary with time and place and antifungal sensitivity is of epidemiological concern as well as significant for the treatment with precision at the current scenario of increasing antifungal resistance. The objectives was to study clinicomycological profile and antifungal sensitivity pattern of commonly used azoles in dermatophytosis.

METHODS

The prospective analysis of 145 clinically suspected cases of dermatophytosis was conducted from January 2014 to January 2015 at Department of Dermatology of COMS, Bharatpur, Chitwan, Nepal. Cases were evaluated and data recorded as per proforma. Samples were collected for microscopy and culture from skin, hair and nail. Antifungal sensitivity pattern was evaluated by standard disk diffusion technique.

RESULTS

Maximum numbers of cases with dermatophytosis were observed between June to September with male to female ratio of 1.4:1. The youngest patient was 3 years and the oldest was 76 years. Tinea corporis (25.5%) was the dominant clnical type observed. Overall direct microscopy (KOH) positivity and culture positivity was 64.8% and 57.2% respectively. Predominant species of dermatophyte isolated was T. mentagrophyte (23.4%). Out of five antifungals used in our study, fluconazole and ketoconazole were found 100% resistant.

CONCLUSIONS

This study highlighted the increasing resistance of the antifungals, which is responsible for the treatment failure in dermatophye infections.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Outcomes of children with abdominal compartment syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations.

OBJECTIVE

To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS.

SETTING

25 bed tertiary pediatric intensive care unit.

PATIENTS

PATIENTS less than 50 kg on mechanical ventilation and a urethral catheter.

MEASUREMENTS

Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored.

MAIN RESULTS

14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondary ACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17 - 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of ≥17 were predictive of developing ACS.

CONCLUSIONS

ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Single donor-derived strongyloidiasis in three solid organ transplant recipients: case series and review of the literature

Donor-derived Strongyloides stercoralis infections in transplant recipients are a rare but recognized complication. In this case series, we report donor-derived allograft transmission of Strongyloides in three solid organ transplant recipients. Following detection of infection in heart and kidney-pancreas recipients at two different transplant centers, a third recipient from the same donor was identified and diagnosed. S. stercoralis larvae were detected in duodenal aspirates, bronchial washings, cerebrospinal fluid, urine and stool specimens. Treatment with ivermectin and albendazole was successful in two of the three patients identified. The Centers for Disease Control and Prevention was contacted and performed an epidemiologic investigation. Donor serology was strongly positive for S. stercoralis antibodies on retrospective testing while all pretransplant recipient serum was negative. There should be a high index of suspicion for parasitic infection in transplant recipients and donors from endemic regions of the world. This case series underscores the need for expanded transplant screening protocols for Strongyloides. Positive serologic or stool tests should prompt early treatment or prophylaxis in donors and recipients as well as timely notification of organ procurement organizations and transplant centers.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.

Contact dermatitis – Pathomechanism and understanding of disease in clinical setting

According to the pathophysiological mechanisms involved, two major types of contact dermatitis recognized irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). The diagnosis of either ICD or ACD is mainly depending on comprehensive clinical data (history and physical examination) as well as by performing appropriate diagnostic patch testing. Two forms of contact dermatitis may differ in early phase of development but development of clinical dermatitis have similar mechanism confusing the clinician and differentiating between ICD and ACD is often difficult in the clinical setting. This review will allow practicing physician to adopt rational clinical approach and the implementation of scientific information for therapeutic as well as preventive strategies. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 70-77 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6816

Erthroplasia of queryat- A case report

Erthroplassia of Queryat (EQ) is a rare squamous cell carcinoma in situ of the penis. It usually occurs on the glans penis and appears as a well-marginated erythematous velvety patch or plaque. Here, we present a case of Erthroplasia of Queryat (EQ). Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 67-69 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6815

Multiple familial trichoepithelioma: A case report

Trichoepithelioma are benign epidermal appendageal tumour with follicular differentiation. Tumor has been categorized into solitary, multiple and desmoplastic types. The multiple familial trichoepithelioma is autosomal dominant inheritance and rarely seen. Journal of College of Medical Sciences-Nepal,2011,Vol-6,No-4, 64-68 DOI: http://dx.doi.org/10.3126/jcmsn.v6i4.6731

An intravenous biological therapy for psoriasis: Infliximab

Psoriasis is a common, chronic inflammatory skin disease which typically follows a relapsing and remitting course and is associated with joint disease. The significant reduction in quality of life and the psychosocial disability suffered by patients underline the need for prompt, effective treatment and long-term disease control. Patients with moderate to severe disease often require systemic treatment with effective & new modalities such as biological-Infliximab. Review will highlight fundamental aspects of infliximab and its use in Psoriasis as well as provide specific comments regarding this monoclonal antibody and its position in of psoriasis in the future treatment. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5977 JCMSN 2011; 7(1): 69-72

"Epizoonosis of dermatophytosis": a clinico- mycological study of dermatophytic infections in central Nepal

BACKGROUND

Identification of dermatophytic species in clinical settings are important not only for epidemiological but also for the treatment.

OBJECTIVES

Present study was carried out to find out the clinical variants of Dermatophytosis and species of fungus responsible for the disease.

METHODS

The prospective observational analysis of 200 clinically suspected cases of dermatophytic infection attending Dermatology department of College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal. Skin scraping, hair and nail samples were collected and processed according to standard protocol.

RESULTS

Maximum number of patients enrolled in study were reported for treatment 5-8 weeks after the onset of disease. Overall male predominance was observed and ages between 26-30 years. Tinea corporis was the most common clinical type of tinea with female dominance in our study. 10 % of cases were having extensive Tinea. 71.5% of samples were positive on direct microscopy and 62 % positive on culture. Samples from T capitis were highest positive by direct microscopy (80%) and over all dominant species of fungus isolated in our study was Trichophyton verrucosum (30.6%).

CONCLUSIONS

The study highlighted Tinea corporis as the most common clinical type with female predominance. Overall predominant causative fungal species isolated was Trichophyton verrucosum.

Candidal infections of ventriculoperitoneal shunts

Although ventriculoperitoneal (VP) shunt infection is a common complication of shunt procedures, fungal infection is considered to be rare. In the present study, we performed retrospective analysis of six cases in which candida infection occurred. In all these six cases, VP shunt was performed in children for hydrocephalus and the onset of symptoms varied between seven days to one month after the surgical procedure was performed. The commonest clinical signs and symptoms were fever (100%), vomiting (100%), and altered sensorium (50%). The commonest isolate was Candida albicans (66.66%) followed by Candida parapsilosis and Candida glabrata in one case each. All the patients were successfully treated with Amphotericin B and there was no mortality recorded.

Vibrio vulnificus Diarrhea in a Child with Respiratory Infection

Vibrio vulnificus is a rare cause of disease and it is often unrecognized and underreported. It is a lactose-fermenting, halophilic vibrio causing severe disease in immunocompromised patients, but causing a mild type of gastroenteritis in healthy people, usually associated with consumption of seafood. We report here a case of diarrhea due to V. vulnificus in a male child who was admitted for fever, loose motions and productive cough. There was no history of consumption of any seafood; so, the source of infection could not be traced. As V. vulnificus is a rare entity, clinicians should have a high index of suspicion for the bacteria, when patients present with gastrointestinal illness, fever or shock, with or without ingestion of raw seafood. Pediatricians should also be alert as the bacterium causes a potentially fatal disease in children.

Renal abscess due to Escherichia coli in a child

Among the various intraabdominal abscesses, renal abscess is a rare entity, especially in children and accounts for a number of cases of "missed diagnoses." Drainage of pus and appropriate antibiotic therapy is the gold standard for treatment. Here we report a case of left renal abscess in a 6-year-old female child secondary to renal calculus. The patient presented with abdominal pain and mild fever for three months and the diagnosis was made by X-ray in the kidney, ureter and bladder (KUB) region, intravenous pyelography and ultrasonography of the abdomen. Escherichia coli was isolated from pus obtained by percutaneous drainage under sonographic guidance. The patient responded to intra-venous ceftriaxone, amikacin, and percutaneous drainage.

Diarrheagenic E. coli in hospitalized patients: special reference to Shiga-like toxin producing Escherichia coli

PURPOSE

This study was conducted to study the prevalence of diarrheagenic Escherichia coli (DEC) in dysentery cases with special reference to Shiga-like toxin producing Escherichia coli (STEC).

METHODS

During a two-year period, 1066 stool samples were collected from hospitalized patients with diarrhea and dysentery. After taking detailed clinical history and observing the gross and microscopic findings of the stool samples, they were cultured on MacConkey and Sorbitol MacConkey agars and E.coli isolates were identified by standard biochemical tests.

RESULTS

Of the 100 E.coli strains isolated in pure culture and sent for sero typing to Central Research Institute (CRI), Kasauli, 43% were found to be DEC, giving an isolation rate of 4.03%. Results of sero typing showed 37.21% STEC which were more common in children. Abdominal pain and stool with mucus flakes were statistically significant parameters (p less than 0.01) in patients with dysentery due to E.coli strains. Though E.coli O157 was not encountered, it was seen that 25% of STEC did not ferment sorbitol. The DEC strains showed maximum in vitro sensitivity to amikacin (83.72%) and all strains were resistant to nalidixic acid. Antibiotics along with ORS and intravenous fluids had to be given in 68.42% patients. As complications, about 16.67% of children developed hemolytic uremic syndrome (HUS),and 10.53% of patients developed acute renal failure. No mortality was reported.

CONCLUSION

Though Enterohemorrhagic E.coli (EHEC) O157:H7 was not encountered in this study, STEC caused by E.coli non O157 was reported. STEC is also known to cause hemorrhagic colitis (HC) and HUS. In this study HUS was reported in 16.67% children. Therefore, proper isolation and identification of STEC is essential in a tertiary care centre, to initiate prompt management and reduce morbidity and mortality in children.

Sporotrichoid pattern of cutaneous nocardiasis due to Nocardia asteroids

Cutaneous nocardiosis is a rare disease, only a few cases of which have been reported from the world as well as in India. This infection, when in the lymphocutaneous form, may clinically resemble sporotrichosis, hence causing a diagnostic dilemma. Here, we report a case of primary cutaneous, sporotrichoid pattern of cutaneous nocardiosis caused by Nocardia asteroides in immunocompetent host. The patient was a 32-year-old farmer, with no predisposing factors, who presented with cutaneous nocardiosis. The diagnosis was confirmed by culture of the biopsy, after which the patient was treated successfully with antibacterial agents.

Neonatal septicaemia in a premature infant due to Candida dubliniensis

Candida dubliniensis is a recently described species that shares many features with Candida albicans. There are very few reports of isolation of this species from bloodstream in adults and paediatric population. Here we report a case of neonatal septicaemia produced by C. dubliniensis in a premature infant admitted to neonatal intensive care unit. The preterm male neonate with a gestational age of 30 weeks and a birth weight of 1.2 kg presented with respiratory distress syndrome for which mechanical ventilation was provided. In spite of receiving antibiotics, the patient developed fever. C.dubliniensis was repeatedly isolated from the blood culture of the patient collected aseptically from different sites. The patient was successfully treated with amphotericin B.

Prostatic abscess by Staphylococcus aureus in a diabetic patient

Prostatic abscess is uncommon and difficult to diagnose because the clinical presentation may mimic symptoms of lower urinary tract infection. We report here a case of prostatic abscess in a 50-year-old known diabetic male patient, who presented with urinary retention. Clinical diagnosis was done by clinical presentation and ultrasonography. The causative agents i.e., Staphylococcus aureus was isolated from the aspirate and the patient responded to intravenous Ciprofloxacin therapy. No other surgical intervention was required to treat the patient.

Fatal rhino-orbito-cerebral infection caused by Saksenaea vasiformis in an immunocompetent individual: first case report from India

A 56-year-old female patient presented with history of nasal blockage, nasal bleeding, headache, since one month. On admission the patient developed severe headache, decreased vision of eyes and blindness. Clinical diagnosis of rhino-orbital involvement was confirmed by computerized tomography of the paranasal sinuses. The diagnosis of fungal infection was confirmed by KOH examination, haematoxylin and eosin examination and Gomori's methanamine silver stain of the biopsy material. Diagnosis was confirmed by culture on Sabouraud Dextrose agar, slide culture on Czapek Dox medium and the isolate was identified as Saksenaea vasiformis. The patient was started on intravenous amphotericin B (received only one dose before succumbing), but she did not respond to the treatment, developed hemiparesis, slurred speech, diminished reflexes and ultimately died. The involvement of the brain was confirmed by computerised tomographic scan. We believe this case to be the first case of rhino-orbito-cerebral infection due to Saksenaea vasiformis and that of second case in an immunocompetent patient in the world.