Enteric fever with severe pancytopenia in a four year girl

Typhoid fever and paratyphoid fever (also known as enteric fever) are severe systemic illnesses caused by salmonella typhi and S. paratyphi respectively. Enteric fever is prevalent in developing countries including Nepal, where it still remains as a major health problem. There have been reports of pancytopenia with enteric fever which has been attributed to mechanisms like bone marrow suppression, infection associated hemophagocytic syndrome and disseminated intravascular coagulation. We report here a case of severe pancytopenia in enteric fever as a result of bone marrow suppression due to systemic infection. Keywords: enteric fever, pancytopenia, bone marrow suppression

Fiber-optic bronchoscopy: seven-year experience at Nepal Medical College Teaching Hospital

Fiber-optic bronchoscopy is a safe and useful diagnostic and therapeutic tool for the management of the pulmonary diseases. The purpose of this study was to find out the demographic profiles, indications, bronchoscopic findings, and diagnoses of the patients who underwent bronchoscopic examination. Retrospective analysis of 231 consecutive bronchoscopies done in Nepal Medical College Teaching Hospital over the period of seven years (January 2003 to January 2010) was done. The commonest indication was radiological opacity (90.2%), followed by diffuse pulmonary infiltrates (4.3%). Cough was the commonest presenting symptom seen in 89.8% of the patients. 79.7% of the patients were smokers and the history of smoking among the patients diagnosed to have lung cancer was 94%. The commonest bronchoscopic finding was endobronchial growth (47.8%). Histopathological examination revealed malignancy in 53.8% of the patients, of which small cell lung cancer was 22.8% and non small cell lung cancer 77.2%. Even when growth was not visualized on bronchoscopy, biopsies attempted from the segments with radiological abnormality established the diagnosis of malignancy in 10.16%, pulmonary tuberculosis in 5.1% and Sarcoidosis in 2.2% of the cases.

Enteric fever with severe pancytopenia in a four year girl

Typhoid fever and paratyphoid fever (also known as enteric fever) are severe systemic illnesses caused by salmonella typhi and S. paratyphi respectively. Enteric fever is prevalent in developing countries including Nepal, where it still remains as a major health problem. There have been reports of pancytopenia with enteric fever which has been attributed to mechanisms like bone marrow suppression, infection associated hemophagocytic syndrome and disseminated intravascular coagulation. We report here a case of severe pancytopenia in enteric fever as a result of bone marrow suppression due to systemic infection.

Esthesioneuroblastoma: a case report

Esthesioneuroblastoma (olfactory neuroblastoma) is an uncommon neuroectodermal tumor. Its biological activity ranges from indolent growth to local recurrence and rapid widespread metastasis. Treatment options consist of surgical resection followed by radiation therapy for primary lesions and the addition of chemotherapy for advanced, recurrent, or metastatic lesions. Patients often present with nasal obstruction, rhinorrhea, recurrent epistaxis, hyposmia, or anosmia. We report a case of esthesioneuroblastoma involving bilateral nasal cavity leading to bilateral nasal obstruction, epistaxis and proptosis of the right eye associated with decreased visual acquity on that eye and loss of smell. A diffuse nontender, 6x6 cms swelling with illdefined margins was seen over the nasal bridge, extending superiorly to glabella and laterally to right maxillary region. X-ray PNS showed soft tissue mass in the nasal cavity with destruction of nasal septum, intense periosteal reaction with destruction of right maxillary wall and extension to right orbit. CT scan of paranasal sinuses showed 8.5 x 4.9 x 7.8 cms irregularly marginated heterogeneous iso- to hyper dense soft tissue mass lesion with extensive adjacent bony destruction and spiculated periosteal reaction involving bilateral nasal cavity and anterior cranial fossa. Biopsy from right nasal mass showed neuroblastoma. The patient received radiotherapy and chemotherapy. The modified Kadish staging system, lymph node status, treatment modality, and age are useful predictors of survival in patients who present with esthesioneuroblastoma. Excellent outcomes for esthesioneuroblastoma are achievable. Long-term follow-up is necessary because of the extended interval for recurrent disease; unlike most sinonasal malignancies, surgical salvage is possible.

Serum bicarbonate: can it be a marker of metformin induced acidosis in geriatrics?

Metformin is an oral antidiabetic agent, widely used in the treatment of type 2 diabetes mellitus. The serious side effect of metformin therapy is lactic acidosis. Contraindications for metformin therapy include renal insufficiency. A cut off value of 60 ml/min in creatinine clearance is suggested. Hundred type 2 diabetics receiving metformin as monotherapy or in combination with insulin/other oral antidiabetic agents, were enrolled in the study. Patients were on metformin for atleast one month prior to being enrolled. Patients' demographic data were taken. Baseline serum creatinine and bicarbonate were estimated. Creatinine clearance (Clcr ml/ min) was calculated. Patients were grouped into group 1-4 depending upon the doses of metformin they received. Patients were again grouped based on their Clcr as groupA (Clcr < 60 ml/min), group B (Clcr > 60.01 ml/min). Data was analysed using student's t test. Out of 100 patients 52 were males, 48 females. Mean age and SD of males and females were 69.92 +/- 6.95 and 66.85 +/- 5.72 respectively. Comparison of mean bicarbonate level in different doses of metformin did not show any statistical significance. But comparison of bicarbonate levels based on Clcr were highly statistically significant (p = 0.0084). In three patients whose bicarbonate level was very low (15, 16.4 and 19.2 mmol/L), doses of metformin was reduced and after one month their bicarbonate levels returned to normal (27.4, 25.6 and 26.2 mmol/L). Hence serum bicarbonate can be a marker to assess metformin induced acidosis in geriatrics patients with low creatinine clearance.

Clinical outcomes of patients with breast cancer in a phase I clinic: The M. D. Anderson Cancer Center experience

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Background: Patients with metastatic breast cancer refractory to standard therapy are eligible for phase I trials. We assessed prognostic factors and clinical outcomes for patients with breast cancer in a phase I clinic focused on targeted agents. Methods: We reviewed the medical records of sequential patients with metastatic breast cancer who presented to our phase I clinic from September 2004 to May 2008. We assessed the relationship between overall survival and patients’ demographic and clinical characteristics using both univariate and multivariate (Cox proportional hazard model) analyses. Results: Ninety-two patients were identified with median age of 53 years (range 28 to 83 years). The median number of prior therapies was 5 (range 1 to 16). The median follow-up of surviving patients is 7.4 months. The median overall survival is 6.7 (95% CI: 5.2, 9.7) months. In univariate analysis, factors predicting shorter survival were elevated Ca-125 (p = 0.001) (Ca27.29 was not significant), albumin < 3.5 g/dL (p = 0.002), worsening ECOG performance status (p = 0.004), absolute neutrophil count < 7.3 x 109/L (p = 0.004), ≥ 10 prior treatment regimens (p = 0.008), ≥ 5 prior chemotherapy-only regimens (p = 0.008), body mass index (BMI) < 25 (p = 0.018), and elevated platelet counts (p = 0.007). In multivariate analysis, independent factors predicting shorter survival were ≥10 prior treatments (vs. <10 prior treatments) (HR = 3.27; 95% CI 1.37, 7.81; p = 0.0077), ECOG performance status 2–3 (vs. 0–1) (HR = 2.92; 95% CI 1.28, 6.66; p = 0.01), and albumin < 3.5 g/dL (vs. > 3.5g/dL) (hazard ratio [HR] = 2.88; 95% CI; 1.41, 5.89; p = 0.004). Of 78 patients treated on a first phase I trial, 14 (18%) demonstrated stable disease (SD), with a median duration of 18 weeks (range 10–25). Of those 19 patients treated on a second phase I trial, 6 (32%) had SD with a median duration of 12 weeks (range 8–17). Two of 4 (50%) patients treated on a third phase I trial had SD with a median duration of 20 weeks (range 16–24). Conclusions: Patients with metastatic breast cancer referred for our phase I studies had a median survival of 6.6 months. In this preliminary analysis, independent factors predicting shorter survival were ≥ 10 prior treatments, worsening ECOG performance status and low albumin levels.

No significant financial relationships to disclose.

Metabolic syndrome among inmates of a 'home for aged' using IDF 2005 criteria

To identify the metabolic syndrome (MetS) among inmates of a 'home for aged' using IDF 2005 criteria. 100 subjects from inmates of a 'home for aged' studied for the identification of metabolic syndrome using International Diabetes Federation (IDF) 2005 criteria. Presence of waist circumference (WC) (Men > or =90 cm, Women > or =80 cm) plus any two of the following four factors; triglycerides (TG) >150 mg/dl (1.7 mmol/l), (II) HDL-Cholesterol (HDL-C) <40 mg/dl (1.0 mmol/l) for men, <50 mg/dl (1.3 mmol/l) for women, fasting plasma glucose (FPG) > or =100 mg/dl (6.1 mmol/l) and blood pressure (BP) > or = 130/85 mm of Hg. Indicated the MetS. MetS was present in 57.0%. WC was common component, TG was increased in 71.9%, low HDL-C present in 86.0%, raised FPG present in 66.7% and hypertension in 45.6%. MetS was more common in older women than in men (63.6% vs. 48.8%) and decreased HDL-C is core components of the MetS in this population. High calorie diet and sedentary life style may be contributing factors of MetS in this population. MetS is common in elderly subjects. It is age-related, and is more common in elderly women.

Pancreatic metastases of renal cell carcinoma--case report

Metastasis to the pancreas from renal cell carcinoma is distinctly uncommon. A solitary renal cell carcinoma (RCC) metastasis to the head of pancreas is rarely encountered. We present a 55 years old male who was admitted in our hospital with the complaint of abdominal pain on and off but more continuous since 15 days. He did not have any urinary symptoms. The laboratory tests were within the normal limits. Ultrasound of abdomen revealed an encapsulate mass in the kidney plus a mass in the head of pancreas, but no other distant metastases. On histopathological examination, sections of the renal mass showed features of a highly vascularized, clear cell neoplasm, with solid, nested, and alveolar architecture, consistent with RCC, clear cell type. Fine needle aspiration from the mass in the head of the pancreas confirmed the diagnosis of metastatic renal cell carcinoma, clear cell type. In the absence of widespread disease, pancreatic resection can provide long term survival in metastatic RCC, although few cases have been reported with lengthy follow up. The prognosis is better than for pancreatic adenocarcinoma.

Ozonolysis of beta-pinene: temperature dependence of secondary organic aerosol mass fraction

The SOA formation from beta-pinene ozonolysis at modest precursor concentrations (2-40 ppb) was investigated in the temperature range of 0-40 degrees C. The presence of inert seeds and high ozone concentrations is necessary to minimize losses of semivolatile vapors to the walls of the smog chamber. beta-pinene secondary organic aerosol production increases significantly with decreasing temperature. An increase by a factor of 2-3, depending on the reacted beta-pinene concentration, was observed as the temperature decreased from 40 to 0 degrees C. This increase appearsto be due mainly to the shifting of partitioning of the semivolatile SOA componentstoward the particulate phase and not to a change of the beta-pinene product distribution with temperature. The measurements are used to develop a new temperature-dependent parametrization for the four-component basis-set. The parametrization predicts much higher SOA production for beta-pinene ozonolysis for typical atmospheric conditions than the values that have been suggested by previous studies.

Rare causes of voice hoarseness: a case report

We report two contrasting and rare cases of voice hoarseness in young patients of tubercular aetiology. First case report is of isolated tubercular recurrent laryngeal nerve palsy in a patient who presented with hoarseness of voice. Chest radiograph showed a left hilar prominence and bronchial washings isolated acid-fast bacilli. Hoarseness of voice as an initial symptom due to isolated vocal cord palsy with no morphological lesions in the larynx and without obvious parenchymal infiltration often poses a diagnostic dilemma. Second case report highlights the possibilities of tuberculosis of the vocal cords mimicking tumour of the larynx. This patient had an ulcerative growth involving the vocal cord which was initially mistaken for malignancy. Patient also had concomitant miliary shadowing in the lungs and laryngoscopic biopsy revealed the growth to be tuberculosis. Early diagnosis and intervention with antitubercular treatment is vital as it results in complete recovery with reversal of vocal hoarseness.

Superior mesenteric artery syndrome: case report

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of 30 years old lady who presented with postprandial abdominal pain at the epigastric region, colic type without radiation accompanied by nausea, postprandial vomiting and weight loss. Esophageal gastric series revealed an abrupt interruption in the contrast medium flow at the level of the junction of third portion (midpart) of the duodenum in barium studies. Adiverticula is noted just proximal to the site of obstruction. High resolution ultrasound and color Doppler sonography showed narrowing of the aortomesenteric angle to 220. Duodenojejunostomy was performed in the patient. Unfortunately the patient later was admitted in the hospital for refractory gastroparesis associated with superior mesenteric artery syndrome. Although open and laparoscopic duodenojejunostomy have been described as the best surgical treatment options for Wilkie's syndrome, but further attention is needed to the management of patients with refractory symptoms of gastroparesis after corrective surgery.

Status of cold-chain maintenance in Chandigarh

An effective cold chain maintenance system is the backbone of success of any immunization program. This study compares the state of cold chain maintenance during intensive pulse polio immunization campaign in union territory of Chandigarh in the year 2001 with that of 2006. The study was conducted during pulse polio rounds of December 2001 and January 2002 and another in April and May 2006 by Department of Community Medicine, Govt. Medical College, Chandigarh. Data was collected from different levels of cold chain maintenance; OPV vials were also collected and sent for potency testing at Central Research Institute, Kasauli in all the rounds. Cold chain sickness rate has decreased from 9.8% in year 2001 to 6% in year 2006. Icepacks were neatly stacked in all the deep freezers (DF) and ice-lined refrigerators (ILR). 94.71% DF's & ILR's were defrosted periodically, 95.36% temperature charts were up-to-date and signed by supervisors and no day carriers were being used in 2006 round. Whereas in 2001, the periodicity of defrosting ILR & DFs was 76.9%, vaccines were stacked neatly in only 38.46% and day carriers were being used. All the randomly selected vaccine samples were reported potent.

Response to high LET radiation 12C (LET, 295 keV/microm) in M5 cells, a radio resistant cell strain derived from Chinese hamster V79 cells

PURPOSE

To study the effects of 12C-beam of 295 keV/microm (57.24 MeV) on M5 and Chinese hamster V79 cells by using cytogenetic assays like micronuclei (MN) induction, chromosomal aberrations (CA) and apoptosis. Additionally, the relative survival of these two cell lines was tested by the colony forming ability of the cells, with a view to understanding the mechanism of cellular damages that lead to difference in cell survival.

MATERIALS AND METHODS

Confluent cells were irradiated with 12C-beam at various doses using 15UD Pelletron accelerator. Cell survival was studied by the colony forming ability of cells. MN assay was done by fluorescent staining. Different types of chromosomal aberrations in metaphase cells were scored at 12 h after irradiation. Apoptosis was measured at different post irradiation times as detected by nuclear fragmentation and DNA ladder was prepared after 48 h of incubation.

RESULTS

Dose-dependent decrease in surviving fractions was found in both the cell lines. However, the surviving fractions were higher in M5 cells in comparison to V79 cells when exposed to the same radiation doses. On the other hand, induced MN frequencies, CA frequencies and apoptosis percentages were less in M5 cells than V79 cells. Very good correlations between surviving fractions and induced MN frequencies or induced total CA or induced apoptosis percentages were obtained in this study.

CONCLUSIONS

The cell strain M5 showed relatively more radio-resistance to 12C-beam compared to Chinese hamster V79 cells in this study. As the MN formation, CA and apoptosis induction were less in M5 cells as compared to parental V79 cells, the higher cell survival in the former could possibly be attributed to their better repairing ability leading to higher cell survival.