A study on pulmonary manifestations in patients with malaria from northwestern India (Bikaner)

BACKGROUND & OBJECTIVES

Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) are responsible for most of the global burden of malaria. With changing spectrum of clinical presentation in malaria, pulmonary system involvement has always been under diagnosed. The present study was planned to estimate the pulmonary system involvement in patients with malaria from north- western India (Bikaner). STUDY DESIGN & DESCRIPTION OF THE PATIENTS: Our study was conducted during 2007 to 2009 in 200 cases of severe malaria [Pf , Pv, and mixed (Pf + Pv)] with pulmonary involvement. It included adult patients of both sexes (145 males and 55 females) belonging to all age groups. The diagnosis of Pf and Pv was confirmed by demonstrating asexual form of parasites in peripheral blood smear and OptiMal test.

MAIN OUTCOME MEASURES

Pulmonary involvement was observed in 30% (60/200) patients among which cough in 24% , dyspnea in 12%, acute respiratory distress syndrome (ARDS) in 7% , bronchitis in 3% and pneumonia in 1.5% were the major clinical manifestations of malaria. Metabolic acidosis and low oxygen saturation was observed in 7% patients. Chest X- ray abnormality in 11.5% patients, 7% had bilateral infiltrates, 1.5% had inflammatory patch and 3% had findings suggestive of bronchitis. Spirometry findings showed 17% patients had early small airway obstruction. All the patients with ARDS had poor disease outcome.

RESULTS & CONCLUSION

Our results suggest that pulmonary system involvement was observed in patients infected with Pf and Pv. If these clinical presentations are ignored, it may lead to delay in diagnosis and can alter the outcome and prognosis of the disease. Therefore, early diagnosis of malaria induced ARDS can significantly affect the outcome.

Zebrafish: from hematology to hydrology

Hemostasis is a defense mechanism that protects an organism from bleeding. Abnormal hemostasis results in bleeding disorders and thrombosis. Several factors are known to control hemostasis in mammals. Despite this progress, more factors remain to be identified. Classical genetic approaches have resolved physiological pathways. However, classical genetics could not be applied completely to hemostasis pathways a decade ago. We introduced zebrafish as a model system to study hemostasis and thrombosis using classical genetic methods. First, we established that zebrafish hemostasis is essentially similar to mammalian hemostasis. Secondly, we developed screening tools for isolating hemostatic mutants. These tools enabled us to identify hemostatic mutants, as well as providing a means to study hemostasis by knockdown methods. Continued characterization of the physiology of thrombus formation led to the novel finding of thrombocyte clustering. Recently, we have discovered that fish secrete proteases, which participate in hemostasis and may have direct relevance in humans. Future work to identify most of the players in thrombus formation is underway.

Biphasic demyelination of the nervous system following anti-rabies vaccination

Acute disseminated encephalomyelitis (ADEM) is an acute or subacute condition characterized by widespread multifocal neurological deficits of variable severity. We report a case of a 45-year-old man with ADEM following anti-rabies vaccine (ARV).

Synthesis of vanillin ethers from 4-(bromomethyl) coumarins as anti-inflammatory agents

4-(Bromomethyl) coumarins 1 have been reacted with vanillins, 2 and 2A to obtain the corresponding ethers 3 and 5. Ethers 3 have been reacted with ethyl cyanoacetate to obtain the unsaturated esters 4. Ethers 5 have been converted to the corresponding 4-(2'-benzo[b] furanyl) coumarins 6 by an intramolecular aldol condensation. Eight compounds have been screened for their anti-inflammatory activity. Out of these the 5,6-benzo-4-2'-benzo[b]furanyl) coumarin (6c) and the aryloxymethyl coumarin (4) with p-formyl group were found to be most active.

Long-term outcome in patients with central neurocytoma following stereotactic biopsy and radiation therapy

Total excision is usually the recommended treatment for central neurocytomas. The role of radiation therapy in their management is controversial, and is usually reserved for partially resected or recurrent tumours. Long-term outcome was studied in patients with central neurocytoma who were treated with radiation therapy. By retrospective chart review, eight patients with intraventricular tumours, who had undergone radiation therapy following stereotactic biopsy, were identified. The diagnosis of neurocytoma was confirmed based on positive immunostaining with synaptophysin. Clinical and radiological follow-up was obtained. Of eight patients, one died 5 years after treatment from shunt dysfunction and 1 had disseminated intracranial disease 15 months after treatment. Six patients were symptom-free at a mean follow-up period of 78 months and had good local control as demonstrated by CT. Since this tumour can be confused with an oligodendroglioma or an ependymoma on routine histopathology (as happened in seven of our cases); immunohistochemical studies with synaptophysin should be routinely performed for intraventricular glial tumours. Our study supports the beneficial effect of radiation therapy in the management of these tumours.

Quantitative study of muscle spindles in suboccipital muscles of human foetuses

The proprioceptive inputs from the cervical musculature play an important role in head-eye co-ordination and postural processes. Deep cervical muscles in humans are shown to have high spindle content. The density, distribution and morphology of muscle spindles were studied in superior oblique capitis, inferior oblique capitis and rectus capitis posterior major and minor three small suboccipital muscles. The muscles were obtained, post-mortem from stillborn human foetus. The spindle density was calculated as the ratio of mean spindle content to the mean wet weight of that muscle in grams. The distribution and arrangement of spindles within the muscle and their arrangement was studied. The spindle density of superior oblique muscle was found to be 190, that of inferior oblique was 242 and the rectus capitis posterior contained 98 spindles per gram of muscle. No tendon organs were seen. The serial transverse sections of inferior oblique muscle revealed muscle spindles of varying sizes, length varying between 100-650 microns and, diameter 50-250 microns. A complex parallel arrangements of group of large spindles were seen in the belly of the inferior oblique muscle, while the polar regions contain few small isolated spindles. The relevance of such high spindle receptor content in these tiny muscles is discussed.

Hypertension in the elderly

OBJECTIVES

To study the clinical profile of hypertension in the elderly, development of end organ complications and the effect of hypertension with other risk factors in producing these complications.

METHODS

One hundred and thirty six elderly patients attending the Hypertension Clinic were included in the study. A detailed history was taken that included presenting illness, family history of hypertension, diabetes, coronary artery disease, dyslipidaemia and history of addictions. Physical examination included systemic examination with measurement of waist to hip ratio and fundoscopy for retinopathy. Renal and liver function tests (RFT, LFT), blood sugar, lipid profile, X-ray chest, electrocardiography (ECG), 2-D echocardiography, abdominal ultrasound and computed tomography (CT) scan head (if indicated) were other important investigations done.

RESULTS

Seventy-nine patients were in the age group of 60-65 years, of which 42 (30.9%) were males. Headache was the commonest chief complaint in 77.9% patients; whereas 24 patients were asymptomatic. Obesity, diabetes, alcohol, dyslipidaemia and family history were important determinants of hypertension. Lipid profile was abnormal in 55.9% patients. Isolated systolic hypertension (ISH) was found in 56.6% patients. Grade II hypertensive retinopathy was observed in 29.4% patients with uncontrolled blood pressure. Left ventricular hypertrophy (LVH) was the commonest ECG manifestation seen in 36.8% patients of which 26.5% had uncontrolled blood pressure. LVH could be diagnosed in 46.4% patients by 2-D echo. Patients with uncontrolled blood pressure and ISH had increased incidence of cardiovascular and cerebrovascular complications. Cardiovascular complications were seen in 19.1% patients having dyslipidaemia and hypertension. Cerebrovascular complications were seen in 15.4% patients having hypertension with LVH. Treatment included calcium channel blockers and/or other drugs.

CONCLUSIONS

The elderly hypertensive patients tend to have ISH. Family history of hypertension is an important determinant of hypertension. Uncontrolled hypertension, ISH, LVH and other associated risk factors are responsible for cardiovascular and cerebrovascular morbidity.

Use of aromatic radical-anions in the absence of THF. Tandem formation and cyclization of benzyllithiums derived from the attack of homo- and bishomoallyllithiums on alpha-methylstyrenes: two-pot synthesis of cuparene

When a homo- or bishomoallyllithium, generated by reductive lithiation of the corresponding phenyl thioether by the radical anion lithium 1-(dimethylamino)naphthalenide (LDMAN), is added to alpha-methylstyrene, a tandem addition/cyclization to a phenyl-substituted five- or six-membered-ring occurs. The yields are compromised by polymerization of the alpha-methylstyrene, a process favored by tetrahydrofuran (THF), the solvent used to generate lithium aromatic radical anions. Thus, a new method of generating LDMAN (unsuccessful for other common radical anions) in the absence of THF has been developed. The radical anion can be generated and the reductive lithiation performed in dimethyl ether at -70 degrees C. After the addition of diethyl ether or other solvent, and evaporation of the dimethyl ether in vacuo, the alpha-methylstyrene is added and the solution is warmed to -30 degrees C. When the unsaturated alkyllithium is primary, no adduct forms in THF due to polymerization of the alpha-methylstyrene, but moderate yields are attained in a solvent containing mainly hexanes. It was also found that the cyclized organolithiums, which would have become protonated in the presence of THF, can be captured by an electrophile, even at ambient temperature. A two-pot synthesis, the most efficient reported, of the sesquiterpene (+/-)-cuparene in 46% yield, using this technology is reported.

Use of aromatic radical-anions in the absence of THF. Tandem formation and cyclization of benzyllithiums derived from the attack of homo- and bishomoallyllithiums on alpha-methylstyrenes: two-pot synthesis of cuparene

When a homo- or bishomoallyllithium, generated by reductive lithiation of the corresponding phenyl thioether by the radical anion lithium 1-(dimethylamino)naphthalenide (LDMAN), is added to alpha-methylstyrene, a tandem addition/cyclization to a phenyl-substituted five- or six-membered-ring occurs. The yields are compromised by polymerization of the alpha-methylstyrene, a process favored by tetrahydrofuran (THF), the solvent used to generate lithium aromatic radical anions. Thus, a new method of generating LDMAN (unsuccessful for other common radical anions) in the absence of THF has been developed. The radical anion can be generated and the reductive lithiation performed in dimethyl ether at -70 degrees C. After the addition of diethyl ether or other solvent, and evaporation of the dimethyl ether in vacuo, the alpha-methylstyrene is added and the solution is warmed to -30 degrees C. When the unsaturated alkyllithium is primary, no adduct forms in THF due to polymerization of the alpha-methylstyrene, but moderate yields are attained in a solvent containing mainly hexanes. It was also found that the cyclized organolithiums, which would have become protonated in the presence of THF, can be captured by an electrophile, even at ambient temperature. A two-pot synthesis, the most efficient reported, of the sesquiterpene (+/-)-cuparene in 46% yield, using this technology is reported.

Unusual "floating balls" appearance of an ovarian cystic teratoma: sonographic and CT findings

Ovarian cystic teratomas are cystic fatty tumors that can be easily diagnosed by sonography and CT. We present a case of ovarian cystic teratoma with an unusual sonographic appearance of mobile, hyperechoic, intracystic fat balls; this finding correlated well with the appearance on CT.

Orbital apex leiomyoma with intracranial extension

BACKGROUND

Leiomyoma is a rare, benign smooth muscle tumor of the orbit. It occasionally shows some histologic resemblance to other common tumors of the orbit like neurofibroma and schwannoma. Its location at the orbital apex is uncommon and only one case with intracranial extension has been reported so far.

CASE DESCRIPTION

A nine-year-old boy presented to us with left orbital pain. Four years earlier he had undergone partial excision, elsewhere, of a tumor at the orbital apex, which was reported as a schwannoma. The computed tomography (CT) scan showed regrowth of the tumor with intracranial extension. The tumor was totally resected by an intracranial route. One year postoperatively there was no recurrence of the tumor.

CONCLUSIONS

Leiomyoma of the orbit, though a benign tumor, does show regrowth after partial excision. Total excision, including any intracranial component, is advised. The cases reported so far are reviewed and the histopathology and possible etiopathogenesis of this tumor are discussed.

Extradural endodermal cyst of posterior fossa: case report, review of the literature, and embryogenesis

OBJECTIVE AND IMPORTANCE

Posterior fossa endodermal cysts are rare. They are located in the midline, in ventral or ventrolateral locations, or intrinsic to the neural axis. Accordingly, various theories of embryogenesis have been proposed. We report the first case of an extradural, dorsolaterally situated endodermal cyst.

CLINICAL PRESENTATION

An adult male patient presented with a short history of headache and cerebellar ataxia. Neuroimaging revealed an extra-axial cystic posterior fossa mass.

INTERVENTION

An entirely extradural cyst was found and was totally excised. Immunohistochemistry confirmed the diagnosis of endodermal cyst.

CONCLUSION

The extradural, dorsal location of the endodermal cyst suggests gaps at the cranial end of the notochord causing ectodermal-endodermal adhesions during early gastrulation and the persistence of endodermal remnants in the dorsal mesenchyme of the blastemal cranium. The literature is reviewed, and proposed theories of embryogenesis are discussed.

Spontaneous intraventricular rupture of craniopharyngioma cyst

BACKGROUND

Rupture of a cystic craniopharyngioma is a rare phenomenon. The rupture of the cyst causes decompression of the adjacent neural structures resulting in spontaneous improvement of the visual symptoms or level of sensorium. The leakage of its contents into the subarachnoid space gives rise to meningismus. We report an extremely rare phenomenon of an intraventricular rupture of a cystic craniopharyngioma, which resulted in acute neurological deterioration and chemical ventriculitis.

CASE DESCRIPTION

A 38-year-old lady presented with a 1-year history of frontal lobe dysfunction and bilateral primary optic atrophy. The CT scan showed a multi-loculated, hyperdense lesion in the region of the third ventricle and suprasellar cistern. She suffered acute deterioration of neurological status; computed tomography (CT) scan showed a hypodense lesion in the suprasellar cistern with persistent hydrocephalus. She was treated with ventricular drainage, steroids and anticonvulsants. Ventricular fluid showed high cholesterol and LDH levels. The diagnosis of craniopharyngioma was subsequently verified histologically. CONCLUSIONS The intraventricular rupture of a cystic craniopharyngioma can result in acute clinical deterioration and morbidity because of chemical ventriculitis. This is unlike the rupture in the subarachnoid space or sphenoid sinus which usually results in symptomatic improvement, although chemical meningitis may occur. This rare phenomenon should be recognized, and prompt ventricular drainage is advised. The literature is reviewed, and management of this condition is discussed.