Erythema Necroticans - A Case Report

Erythema Nodosum Leprosum (ENL) is characterized by evanescent, erythematous, painful raised nodules which fade within 48-72 hours. Necrotic and ulcerative forms are rare presentations of severe ENL. A 27 year old male patient presented with multiple erythematous nodules on trunk and extremities associated with high grade fever, joint pain and pedal edema. Patient developed ulceration of nodules associated with pain and burning sensation over another 3 days. Slit smear showed clumps of granular bacilli. Biopsy showed superficial dermis showing edema with dense focal perivascular infiltrate of lymphocytes, macrophages and few scattered neutrophils. Fite-Faraco stain was negative. Patient was diagnosed as a case of erythema necroticans and started on oral steroids and thalidomide. The histological findings illustrate the need to consider leprosy diagnosis in necrotizing vasculitis even when Virchow's cells are not found in the infiltrate. Thalidomide is the drug of choice in such cases. This patient showed a marked response to the drug with healing of all ulcers within 2 weeks of starting thalidomide.

Neuropathies in the Rheumatoid Patient: A Case of the Heavy Hand

Rheumatoid Arthritis (RA) is a common inflammatory arthritis' with pain and loss of function among its most disabling symptoms. These are mostly secondary to inflammation or mechanical damage to the joints. However it is also important to consider disease complications as a cause of symptoms, especially when the response to treatment is suboptimal. We report an RA patient whose symptoms were resistant to standard therapy, and were actually due to peripheral neuropathy.

Collapsing glomerulopathy in a case of anti-neutrophil cytoplasmic antibody associated vasculitis

Collapsing glomerulopathy (CG) is a pathological entity characterized by collapse and wrinkling of glomerular tuft, podocyte dedifferentiation and hyperplasia. CG may be idiopathic or secondary to other diseases. CG has been described with IgA nephropathy, membranous glomerulopathy, diabetic nephropathy, and lupus nephritis. However, till date there is no report of CG in association with the anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). Here, we present a case of CG that developed during follow-up in a case of AAV with biopsy proven pauci-immune glomerulonephritis.

An unusual case of cocoon abdomen in a patient on hemodialysis

“Cocoon abdomen” or sclerosing encapsulating peritonitis is a rare cause of intestinal obstruction. It has been described in patients on continuous ambulatory peritoneal dialysis. The exact etiology is unknown, but pathogenesis rests on chronic peritoneal inflammation. No case has been reported so far in patients on hemodialysis. We hereby report a case of cocoon abdomen presenting as refractory ascites with intestinal obstruction in a patient on maintenance hemodialysis.

Plasma exchange in Immunoglobulin A nephropathy with thrombotic microangiopathy and acute cortical necrosis

A 25-year-old female presented with decreased urine output, deranged renal function, thrombocytopenia, and hemolytic anemia. Kidney biopsy was consistent with thrombotic microangiopathy with acute cortical necrosis and Immunoglobulin A nephropathy (IgAN). Hemolytic anemia, thrombocytopenia and urine output improved after five sessions of plasma exchange. Renal function showed a delayed recovery and serum creatinine normalized by 3 months. This is first case of successful use of plasma exchange in hemolytic uremic syndrome with cortical necrosis associated with IgAN.

Standards for TB care in India: A tool for universal access to TB care

In 2014, Government of India in collaboration with World Health Organization Country Office for India released the policy document on Standards for tuberculosis (TB) care in India after in-depth deliberation with national and international experts. The standards for TB care represent what is expected for quality TB care from the Indian healthcare system including both public and private systems. The details of each standard have been compiled in this review article. It is envisioned that the standards detailed in the manuscript are adapted by all TB care providers across the country.

Modulating role of pheromonal cues from oestrus-specific urine on 3-methylcholanthrene-induced male reproductive toxicity

Polyaromatic hydrocarbons (PAHs) are persistent organic pollutants that contribute to endocrine/gonadal disruption. This study was designed to investigate the endocrine modulating role of pheromones in alleviating the reproductive toxic effects of 3-MC (3-methylcholanthrene), one of the common PAHs, in rat model. The rats were injected intraperitoneally with 3-MC at a dose of 25 mg kg(-1) BW. The serum levels of testosterone and other biochemical parameters were altered to significant levels in 3-MC-treated rats and oestrus-specific urine exposure restored all these effects to near normal. Although testis weight did not indicate any significant change, sperm and spermatid counts were significantly reduced in 3-MC-treated rats, which became normal in oestrus-urine-exposed rats. Hence, this study suggests that oestrus-specific urinary pheromones have the potential to modulate the endocrine system and alleviate the male reproductive toxic effects produced by 3-MC.

A study on male homosexual behavior

INTRODUCTION

Male homosexual behavior carries a high risk of transmitting sexually transmitted infections (STIs). Ignorance regarding the associated high risk, indulgence inspite of no natural homosexual orientation and not using protective barrier methods can affect the sexual health of adolescents and adults.

AIM

(1) To assess the proportion of men who have sex with men (MSM) having a natural homosexual orientation compared to those who had acquired the homosexual behavior initially under various circumstances (such as due to certain misconceptions, fear of having heterosexual contact, peer pressure, and influence of alcohol). (2) To assess the level of awareness regarding increased risk of transmission of STIs associated with homosexual behavior and regarding protective barrier methods.

MATERIALS AND METHODS

After obtaining consent from the subjects, questionnaire - based interview used for obtaining data for this observational (cross-sectional) study.

RESULTS

(1) Of the 50 subjects, only about 25% had interest in homosexual behavior prior to initial episode. (2) About 50% subjects indulged in homosexual behavior due to lack/fear of having heterosexual contact. (3) About 60% subjects believed that homosexual behavior carried relatively lower risk of acquiring STIs and 68% subjects have had unprotected contact. (4) About 70% subjects had only acquired this behavior and nearly 60% subjects were interested in heterosexual marriage and not interested in further homosexual behavior.

CONCLUSION

(1) Homosexuality is a natural orientation in some and an acquired behavior in the rest. (2) If homosexual behavior is acquired, due to misconceptions, then imparting sex education and awareness regarding involved risks, and the importance of protective barrier methods will prevent ignorance driven behavior. For those with natural homosexual orientation, the importance of protective barrier methods in homosexual behavior needs emphasis.

Proliferative glomerulonephritis with monoclonal immunoglobulin deposition disease: The utility of routine staining with immunoglobulin light chains

Proliferative glomerulonephritis occurring as a consequence of monoclonal glomerular deposits of IgG is uncommon. It is a form of renal involvement in monoclonal gammopathy that mimics immune complex glomerulonephritis. Here, we report the first series of proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) from the Indian subcontinent highlighting use of light chain immunofluorescence (IF) in routine renal biopsy interpretation. We retrieved 6 patients diagnosed as proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) out of 160 biopsies (3.7%) with membranoproliferative patterns over 5 1/2 years (2009-2014), one of whom had recurrence 6 months post-renal transplant. Four (67%) patients presented with rapidly progressive renal failure and two (33%) with nephrotic syndrome. None of these patients had overt multiple myeloma. The predominant histologic pattern was membranoproliferative with all the biopsies showing IgG3 Kappa deposits on IF. The deposits were primarily subendothelial on electron microscopy.

Drug-induced acute interstitial nephritis: A clinicopathological study and comparative trial of steroid regimens

Steroids are used in the management of drug-induced acute interstitial nephritis (AIN). The present study was undertaken to compare the efficacy of pulse methyl prednisolone with oral prednisolone in the treatment of drug-induced AIN. Patients with biopsy-proven AIN with a history of drug intake were randomized to oral prednisolone (Group 1) 1 mg/kg for 3 weeks or a pulse methyl prednisolone (Group II) 30 mg/kg for 3 days followed by oral prednisolone 1 mg/kg for 2 weeks, tapered over 3 weeks. Kidney biopsy scoring was done for interstitial edema, infiltration and tubular damage. The response was reported as complete remission (CR) (improvement in estimated glomerular filtration rate [eGFR] to ≥60 ml/min/1.73 m(2)), partial remission (PR) (improvement but eGFR <60 ml/min/1.73 m(2)) or resistance (no CR/PR). A total of 29 patients, Group I: 16 and Group II: 13 were studied. Offending drugs included nonsteroidal anti-inflammatory drugs, herbal drugs, antibiotics, diuretic, rifampicin and omeprazole. There was no difference in the baseline parameters between the two groups. The biopsy score in Groups I and II was 5.9 ± 1.1 and 5.1 ± 1.2, respectively. At 3 months in Group I, eight patients each (50%) achieved CR and PR. In Group II, 8 (61%) achieved CR and 5 (39%) PR. This was not significantly different. Percentage fall in serum creatinine at 1 week (56%) was higher in CR as compared to (42%) those with PR. (P = 0.14). Patients with neutrophil infiltration had higher CR compared to patients with no neutrophil infiltration (P = 0.01). Early steroid therapy, both oral and pulse steroid, is equally effective in achieving remission in drug-induced AIN.

Mycosynthesis of silver and gold nanoparticles: Optimization, characterization and antimicrobial activity against human pathogens

This study was aimed to isolate soil fungi from Kolli and Yercaud Hills, South India with the ultimate objective of producing antimicrobial nanoparticles. Among 65 fungi tested, the isolate, Bios PTK 6 extracellularly synthesized both silver and gold nanoparticles with good monodispersity. Under optimized reaction conditions, the strain Bios PTK 6 identified as Aspergillus terreus has produced extremely stable nanoparticles within 12h. These nanoparticles were characterized by UV-vis. spectrophotometer, HR-TEM, FTIR, XRD, EDX, SAED, ICP-AES and Zetasizer analyses. A. terreus synthesized 8-20 nm sized, spherical shaped silver nanoparticles whereas gold nanoparticles showed many interesting morphologies with a size of 10-50 nm. The presence and binding of proteins with nanoparticles was confirmed by FTIR study. Interestingly, the myco derived silver nanoparticles exhibited superior antimicrobial activity than the standard antibiotic, streptomycin except against Staphylococcus aureus and Bacillus subtilis. The leakage of intracellular components such as protein and nucleic acid demonstrated that silver nanoparticles damage the bacterial cells by formation of pores, which affects membrane permeability and finally leads to cell death. Further, presence of nanoparticles in the bacterial membrane and the breakage of cell wall were also observed using SEM. Thus, the obtained results clearly reveal that these antimicrobial nanoparticles could be explored as promising candidates for a variety of biomedical and pharmaceutical applications.

Age-related differences in the use of total shoulder arthroplasty over time

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test.

The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100 000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001).

The rates of use of TSA/100 000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p <  0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p <  0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001).

In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes.

Cite this article: Bone Joint J 2015;97-B:1385–9.

Transitioning to daily treatment for drug-sensitive TB in India

World Health Organization in its treatment guideline for tuberculosis 2010 recommended daily dosing as the preferred regimen in treatment of drug-sensitive TB patients. The Revised National Tuberculosis Control Program took a decision to implement daily regimen in five states of India in 2015. This article describes the policy-making chronology, evidences used, stakeholders involved, and process of decision making.

Light chain proximal tubulopathy with cast nephropathy in a case of multiple myeloma

The renal diseases most frequently associated with myeloma include cast nephropathy (CN), amyloidosis and monoclonal immunoglobulin deposition disease. Light chain proximal tubulopathy (LCPT) is reported less frequently. Majority of the cases with κ-restriction present with Fanconi syndrome (FS) and show crystals in proximal tubular epithelial cytoplasm. In contrast, those with λ-restriction are infrequently associated with FS and show cytoplasmic vacuolations in proximal tubular epithelial cytoplasm. Combination of morphologies in kidney affected by plasma cell dyscrasias is rare and co-existence of LCPT and CN is one of the rarest. We report a case of multiple myeloma having this rare combination of morphologies.

Comparison of the utility of Cocaine- and Amphetamine-Regulated Transcript (CART), chromogranin A, and chromogranin B in neuroendocrine tumor diagnosis and assessment of disease progression

CONTEXT

Prognosis in patients with neuroendocrine tumors (NETs) is often poor, frequently reflecting delayed diagnosis. Hence, accurate and practical NET markers are needed. Cocaine- and amphetamine-regulated transcript (CART) peptide is a potential novel NET marker.

DESIGN AND PARTICIPANTS

Circulating levels of CART peptide and the established NET markers chromogranin A (CgA) and chromogranin B (CgB) were measured using RIA in 353 patients with NET (normal renal function) and in controls. Clinical data were collected retrospectively.

MAIN OUTCOME MEASURE(S)

The comparative and combined utility of CART, CgA, and CgB for diagnosis and assessment of disease progression was measured in different NET subtypes.

RESULTS

CgA and CgB in combination improved diagnostic accuracy in patients with gut NETs, nongastroenteropancreatic NETs, and NETs with an unknown primary origin compared with each biomarker alone. Measuring CART did not further improve diagnosis in these NET subtypes. For pancreatic NETs, CgB was superior to CgA and CART in detecting stable disease (P < .007), whereas CgA and CART in combination were most effective in identifying progressive disease. In phaeochromocytomas/paragangliomas (PCC/PGL), CART was the most useful biomarker for identifying stable (P < .001) and progressive (P = .001) disease. Consistent with this, plasma CART decreased following PCC/PGL tumor resection, remaining low in all patients in remission, but increasing in those with progressive disease.

CONCLUSIONS

CART is a useful marker for identifying progressive pancreatic NETs. CART is superior to CgA and CgB in detecting stable and progressive PCC/PGLs, and may have a role as a surveillance marker for PCC/PGL patients.

Rapidly progressive renal failure in a patient with extranodal non-Hodgkin's lymphoma

A 60-year male was admitted with advanced renal failure and bilaterally enlarged kidneys. Kidney biopsy revealed diffuse interstitial infiltration by CD20 + lymphomatous cells suggestive of diffuse large B-cell, non-Hodgkin's lymphoma. Bone marrow examination was negative for malignant cells. Positron emission tomography-computed tomography showed uniformly diffuse and avid flurodeoxy glucose uptake in both kidneys, multiple hypodense areas of both lobes of liver, and axial and appendicular skeleton. Patient was treated with rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine and prednisolone, became afebrile and serum creatinine normalized.

Successful induction of granulomatosis with polyangiitis with tacrolimus

We report a 50-year-old female who presented with inflammatory arthritis, upper respiratory tract symptoms, and microscopic hematuria with nephrotic range proteinuria. Antineutrophil cytoplasmic antibodies (ANCA) were detectable and kidney biopsy showed pauci-immune focal necrotizing crescentic glomerulonephritis. She was treated with pulse intravenous cyclophosphamide (CYC) and prednisolone. Patient developed severe leucopenia after the first dose and subsequently had leucopenia to low dose CYC, mycophenolate mofetil and azathioprine were also tried. However, patient developed leukopenia with all the above agents. Initiation of tacrolimus (TAC) was followed by dramatic response: Proteinuria decreased, serum albumin normalized and C-ANCA and anti-PR3 ANCA assays became negative. This is the first successful case of TAC as an induction agent in a patient with GPA (ANCA associated vasculitis with renal involvement).

A study on male homosexual behavior

INTRODUCTION

Male homosexual behavior carries a high risk of transmitting sexually transmitted infections (STIs). Ignorance regarding the associated high risk, indulgence inspite of no natural homosexual orientation and not using protective barrier methods can affect the sexual health of adolescents and adults.

AIM

(1) To assess the proportion of men who have sex with men (MSM) having a natural homosexual orientation compared to those who had acquired the homosexual behavior initially under various circumstances (such as due to certain misconceptions, fear of having heterosexual contact, peer pressure, and influence of alcohol). (2) To assess the level of awareness regarding increased risk of transmission of STIs associated with homosexual behavior and regarding protective barrier methods.

MATERIALS AND METHODS

After obtaining consent from the subjects, questionnaire - based interview used for obtaining data for this observational (cross-sectional) study.

RESULTS

(1) Of the 50 subjects, only about 25% had interest in homosexual behavior prior to initial episode. (2) About 50% subjects indulged in homosexual behavior due to lack/fear of having heterosexual contact. (3) About 60% subjects believed that homosexual behavior carried relatively lower risk of acquiring STIs and 68% subjects have had unprotected contact. (4) About 70% subjects had only acquired this behavior and nearly 60% subjects were interested in heterosexual marriage and not interested in further homosexual behavior.

CONCLUSION

(1) Homosexuality is a natural orientation in some and an acquired behavior in the rest. (2) If homosexual behavior is acquired, due to misconceptions, then imparting sex education and awareness regarding involved risks, and the importance of protective barrier methods will prevent ignorance driven behavior. For those with natural homosexual orientation, the importance of protective barrier methods in homosexual behavior needs emphasis.

Study of hypothalamic pituitary adrenal axis in patients of membranous nephropathy receiving modified Ponticelli regimen

Pulse methyl prednisolone followed by oral prednisolone and abrupt switch to chlorambucil/cyclophosphamide (Ponticelli/modified Ponticelli regimen) is used in patients with idiopathic membranous nephropathy. This therapy where steroids are stopped abruptly is unphysiologic and expected to have hypothalamic pituitary adrenal (HPA) axis suppression; however, this has not been evaluated. A total of 13 consecutive adult patients with idiopathic membranous nephropathy who had completed modified Ponticelli regimen were studied. The regimen included administration of pulse methylprednisolone 1 g for 3 days followed by oral prednisolone 0.5 mg/kg/day for 27 days followed by oral cyclophosphamide at a dose of 2 mg/kg/day for the next month. This was repeated for three courses. Patients who had received corticosteroids prior to therapy were excluded. The HPA axis was evaluated after 1 month of completing the last course of steroid therapy. The evaluation was done using a low-dose adrenocorticotropic hormone stimulation test. A single intravenous bolus dose of synacthen (1 μg) was given at 9.00 am and the serum cortisol levels were estimated by radioimmunoassay at 0, 30, and 60 min. A peak cortisol level of 550 nmol/L or higher was considered as normal. Mean baseline cortisol levels was 662.3 ± 294.6 nmol/L and peak cortisol level was 767 ± 304.4 nmol/L. A total of 6 patients (46.2%) had low basal cortisol levels, only 3 (23%) had both basal and peak cortisol levels < 550 nmol/L suggestive of HPA axis suppression. To conclude, 23% of patients had suppression of HPA axis after modified Ponticelli regimen.