Clinical expression and EEG features of patients with juvenile myoclonic epilepsy (JME) from North India

We aimed to characterize the clinical profile, EEG features and response to treatment of juvenile myoclonic epilepsy (JME) patients. We studied 103 JME probands with a standard protocol recording age of onset, type, frequency of seizures, EEG data, detailed family history and response to treatment in a superspeciality university hospital in New Delhi. The mean age of onset of disease was 14.01 +/- 3.14 years with a male to female ratio of 1.19 : 1. The myoclonic jerks were present in all the probands, generalized tonic-clonic seizures (GTCS) were present in 75.72% and 11.65% probands had absence seizures. The incidence of febrile convulsion (FC) was higher (9.7%) in our JME probands reflecting some ethnic variation or ascertainment bias. There was a considerable delay (of approximately 5.26 +/- 4.61 years) in the diagnosis of JME in our probands because most of the patients were referred from private physicians who were possibly not familiar with this epileptic syndrome in this part of the world or thought it was a milder variety of GTCS. The family history was positive in 25.24% JME probands among first- and second-degree relatives. An interictal EEG was found to be abnormal in 81 (78.64%) patients with the predominant abnormality being generalized polyspike and wave (PSW) discharges (39.80% probands). The majority of patients (80.58%) showed a good response to treatment with valproate alone. There was a subset of patients (11.65%) who required the addition of other antiepileptic drugs (AEDs) for control of GTCS: 7.76% of JME patients were diagnosed as cases of GTCS by private practitioners before they were registered in our study and their seizures were well controlled on other AEDs (without valproate) prescribed by the referring physicians (carbamazepine-4, phenytoin-2, clobazam-2). It is concluded that the clinical features and EEG data of JME probands were comparable to reports from other parts of the world except for the fact that the incidence of FC was higher in our JME patients. There was a delay in the diagnosis of JME due to unfamiliarity with the epileptic syndrome among private practitioners in this part of the world. There was a subset of JME patients who had complete seizure control on other AEDs besides valproate.

Panniculitides--a clinicopathologic study

OBJECTIVES

To describe the clinical and pathologic features of panniculitides, an uncommon group of diseases, where the available Indian literature is sparse.

MATERIAL AND METHODS

Prospective four years study of patients presenting with panniculitis to a large teaching hospital in North India.

RESULTS

Erythema nodosum (EN) was the commonest panniculitis (79.3% cases) in our cohort. Other causes included erythema induratum, Weber Christian disease, cutaneous polyarteritis nodosa and panniculitis associated with Takayasu's arteritis and dermatomyositis-lupus overlap. Elevated ESR and leukocytosis were the common laboratory abnormalities encountered. Septal panniculitis without vasculitis was the most frequent histopathologic pattern observed. Patients of EN did well on nonsteroidal anti-inflammatory drugs while corticosteroids with or without azathioprine were used to treat other panniculitides.

CONCLUSIONS

Physician awareness, clinical pattern recognition and histopathological confirmation, all play a key role in the identification and management of panniculitis.

Visual evoked potential & brainstem auditory evoked potentials in acute attack & after the attack of migraine

PURPOSE

To study the effect on visual evoked potential (VEP) and brainstem auditory evoked potential (BAEP) at time of acute attack and after 7 days of the attack of migraine.

MATERIAL AND METHODS

We studied BAEP and pattern reversal VEP in 25 patients during acute attack and after 7 days of the attack. The diagnosis of migraine was established according to criteria given by international headache society (IHS). Peak and interpeak latencies (IPL's) of BAEP and P100 latency of VEP were the main criteria to judge abnormalities.

RESULTS

There were prolonged peak and interpeak latencies in BAEP and prolonged peak latency (P100) in VEP at the time of acute attack of migraine. The data of these abnormal recording were highly significant. After 7 days when the attack was over, we recorded the BAEP and VEP again. The observation obtained at this time was comparable to normal values.

CONCLUSIONS

From the observation of this study we can safely conclude that in acute attacks of migraine there may be some pathological changes in different areas of brain and brainstem, producing changes in evoked potential which are statistically highly significant. However, these changes are reversible, as the values of BAEP & VEP on 7th day after the attack were comparable to those observed in normal healthy control.

Species distribution and antibiotic sensitivity pattern of Coagulase negative staphylococci isolated from various clinical specimens

A study of 192 strains of Coagulase negative staphylococcus (CONS) showed that Staphylococcus epidermidis was the most common species, 158 (82.29%) isolated from all clinical specimens followed by S. saprophyticus (30, 15.62%) isolated mainly from urine. Slime production was exhibited by 77 (48.7%) strains of S. epidermidis and 8 (26.6%) of S. saprophyticus and the difference in the slime producing activity was statistically significant (p< 0.005). Antibiotic susceptibility testing against 15 commonly used antibiotics showed multidrug resistance with more than 90% resistance to penicillin, more than 50% to cephalexin and ciprofloxacin and more than 20% to methicillin, thus, highlighting the importance of species identification and antibiotic susceptibility testing for clinical isolates of CONS.

Status of physical exercise and its association with obesity and hypertension in two urban assembly constituencies of East Delhi

In a community based study using systematic random sampling in two urban Assembly constituencies in East Delhi, 420 subjects above the age of 30 years were interviewed to find out their status regarding physical exercise. People doing regular exercise were found to be only 44.8%. The commonest reason associated for not doing/irregular physical exercise was nonavailability of time (63.3%), followed by no need felt by the respondents to exercise (23.3%). The prevalence of obesity in the group doing regular exercise was much lower than the group that was not doing regular exercise and the results were statistically significant. Though a similar association was found with hypertension also, the results were not statistically significant.

A clinico-bacteriological study of peripheral tuberculous lymphadenitis

OBJECTIVE

Tuberculous lymphadenitis is the commonest form of extra-pulmonary tuberculosis. It is most often caused by M. tuberculosis though several reports from other countries have shown mycobacteria other than tuberculosis (MOTT) to be responsible for a significant proportion of tuberculous lymphadenitis cases. The present study was conducted to find the prevalence of M. tuberculosis and MOTT as aetiological agents in patients with peripheral tuberculous lymphadenitis.

METHODS

A total of 138 patients with tuberculous lymphadenitis were included in the study. Diagnosis of tuberculosis was established on the basis of fine needle aspiration cytology, histopathology, presence of mycobacteria on Ziehl Neelson stain or auramine rhodamine stain, or aspiration of pus with negative Gram's stain and pyogenic cultute with radiologic evidence of pulmonary tuberculosis. Mycobacterial cultures were performed on aspirated material and species identified using standard methods.

RESULTS

Of 138 patients, single lymph nodal enlargement was found in 48.6% patients while others had more than one lymph nodes. Lymph nodes were matted in 26.8% cases while fluctuation could be elicited in 12.3% patients. Chest X-ray showed evidence of active pulmonary lesions or mediastinal lymphadenopathy in 28.3% cases. The fine needle aspiration cytology was positive for tuberculous lymphadenitis in 41.3% cases while it revealed granulomas or necrosis in another 13% cases. The Ziehl-Neelson and the auramine-rhodamine staining were positive in 19.6% and 26.8% patients, respectively. On culture, the lymph node aspirate was positive for Mycobacterium species in 40.6% patients. In all but two cases, the culture revealed presence of Mycobacterium tuberculosis. The other two cultures revealed growth of Mycobacterium fortuitum chelonae complex. Of the two HIV-positive patients, M. tuberculosis could be isolated in one case.

CONCLUSION

Findings of this study suggest that M. tuberculosis is still the most common cause of tuberculous lymphadenitis and MOTT are responsible for very few cases. However, such studies need to be carried out frequently at various centres so as to see any periodic and geographic variations within India.

A study of autoimmune markers in hepatitis C infection

BACKGROUND & OBJECTIVES

Hepatitis C virus (HCV) infection is associated with several autoimmune markers. Despite HCV being common in India, no information on this aspect is available. This study was undertaken to ascertain the frequency and clinical significance of autoimmune markers like rheumatoid factor (RF), antinuclear antibodies (ANA), antibodies to double stranded deoxyribonucleic acid (dsDNA), anti neutrophil cytoplasmic antibody (ANCA), anti smooth muscle antibodies (ASMA), anti liver kidney microsomal 1 antibodies (anti LKM1), anti gastric parietal cell antibodies (anti GPCA), anti mitochondrial antibodies (AMA), anti cardiolipin antibodies (ACL) and cryoglobulins in HCV infection and to determine the effect of treatment on these markers.

METHODS

Twenty five patients with chronic hepatitis C and 25 healthy controls were studied. Cryoglobulins were detected by cryoprecipitation, RF by latex agglutination, anti dsDNA and ACL by ELISA while indirect immunofluorescence was used to detect all other autoantibodies.

RESULTS

Eighteen patients (72%) demonstrated autoimmune markers. RF, cryoglobulins and anti LKM1 antibodies were the most frequently detected markers (in 32% patients each). ASMA, perinuclear ANCA (pANCA), ANA and anti GPCA were seen in 24, 20, 12 and 4 per cent patients respectively. None of the patients exhibited ACL, AMA or antibodies to dsDNA. No antibodies were detected in healthy controls. Sixty per cent of the patients had rheumatological symptoms. Of the seven patients followed up after treatment with alpha interferon, only two exhibited persistence of RF, while symptoms and other markers disappeared.

INTERPRETATION & CONCLUSION

Rheumatological symptoms and autoimmune markers are common in HCV infection and are usually overlooked. Patients with unexplained joint pains and/or palpable purpura should be screened for HCV. Further studies are needed to delineate fully the link between infection and autoimmunity.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study

OBJECTIVE

To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA).

MATERIAL AND METHODS

Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study.

RESULTS

We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA.

CONCLUSIONS

The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

Seroepidemiology and active surveillance of dengue fever/dengue haemorrhagic fever in Delhi

The aims of the present study were to carry out surveillance for dengue virus infection in adults with short-duration fever, and serological study of dengue virus infection in persons without fever. Patients were divided into two groups. Group 1 included patients above 12 years of age with fever of 2-12 days duration without any apparent cause. Of these, patients who presented with fever for 2-5 days were included for virus isolation (group 1a) while those who presented within 6-12 days of the onset of fever were included for the dengue-specific IgM serology (group 1b). Group 2 included a sample of population belonging to all age groups but without pyrexia and blood was collected for dengue-specific IgG serology. Twenty-six patients were enrolled in group 1a over a period of 4 months (September to December, 1997). Of these, DEN1 was isolated in 5 cases. Group 1b included 182 patients, out of which 34 (18.68%) were positive for dengue-specific IgM antibodies. Significantly, all the positive cases were detected during the months of September to November. Retro-orbital pain was present in a significantly more number of IgM-positive cases as compared to IgM-negative cases. Group 2 included 125 cases without fever. The overall positivity for dengue-specific IgG antibodies was 77.6%, with the highest positivity of 100% in the age group of 31-40 years. It was concluded that dengue virus infection is endemic in and around Delhi with peak incidence between September and Novemver. The prevalent serotype during September and December 1997 was DEN1. Since previous epidemic of DHF was due to DEN2 type, isolation of DEN1 serotype indicates changes of another epidemic of DHF due to DEN1 serotype. The stresses the urgent need for implementation of measures to control the transmission of dengue infection.

Identification of mtDNA mutation in a pedigree with gestational diabetes, deafness, Wolff-Parkinson-White syndrome and placenta accreta

Mitochondrial DNA (mtDNA) defects are associated with a number of human disorders. Although many occur sporadically, maternal transmission is the hallmark of diseases due to mtDNA point mutations. The same mutation may manifest strikingly different phenotypes; for example, the A to G substitution at np 3243 was first reported in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (the MELAS syndrome), but is also found in patients with diabetes and deafness. Here we present a case of gestational diabetes, deafness, premature greying, placenta accreta and Wolff-Parkinson-White (WPW) syndrome associated with a mtDNA mutation. Although this is the first report of such an association, study of 27 other patients with WPW syndrome failed to confirm that this mtDNA mutation is a common cause of such pre-excitation disorders.

Estrogen replacement does not prevent the loss of choline acetyltransferase-positive cells in the basal forebrain following either neurochemical or mechanical lesions

Recent studies have shown that estrogen replacement can enhance the functional status of basal forebrain cholinergic neurons. Studies have also shown that estrogen has neuroprotective effects both in vitro and in vivo on a variety of cells and against a variety of insults. The present study examined the ability of estrogen replacement to protect basal forebrain cholinergic neurons from the effects of neurochemical and mechanical injury. Ovariectomized Sprague-Dawley rats received either estrogen replacement or sham surgery, and then received either a unilateral injection of ibotenic acid into the nucleus basalis magnocellularis, or unilateral transection of the fimbria fornix. Cholinergic neurons in the medial septum and nucleus basalis were detected and quantified using immunohistochemical techniques. The data show that neither 3 weeks nor 13 weeks of continuous estrogen replacement prevented the loss of choline acetyltransferase (ChAT)-containing cells in the nucleus basalis following a unilateral injection of ibotenic acid. Likewise, estrogen replacement did not prevent a decrease in ChAT-positive cells detected in the medial septum following unilateral transection of the fimbria fornix. Notably, increased numbers of ChAT-positive cells were detected in the contralateral nucleus basalis, and in the ipsilateral and contralateral medial septum, at 2 weeks following a unilateral injection of ibotenic acid into the nucleus basalis; however, these effects were not related to hormone treatment. These data suggest that estrogen replacement does not protect cholinergic neurons in the medial septum and nucleus basalis from the effects of excitotoxic or mechanical injury.

Ultrasonographic assessment of gall bladder kinetics in the elderly

BACKGROUND

The incidence of gallstones increases with age but the factors that influence gallstone formation in the elderly are poorly understood. Proposed factors include changes in bile composition and hypomotility of the gall bladder. Studies on gall bladder motility in the elderly have provided conflicting results, and none has been reported from India.

AIM

To determine gall bladder contractility in healthy elderly subjects and compare it with that in young healthy volunteers.

METHODS

Thirty healthy elderly (above the age of 60 years) and 30 young volunteers with no abdominal complaints were studied. Using real-time ultrasonography and the ellipsoid method, gall bladder volume was measured after overnight fast and at 10, 20, 30, 40, 50 and 60 minutes after a standard fatty meal. Residual volume, delta volume and ejection fraction were calculated.

RESULTS

Mean fasting gall bladder volume in elderly subjects was higher than that in young subjects (13.5 [5.8] mL vs 10.9 [3.6] mL; p < 0.05). However, there was no difference in the 60-min postprandial residual gall bladder volumes in the two groups. Change in gall bladder volume and ejection fraction were also similar in the two groups.

CONCLUSION

There was no difference in gall bladder emptying between elderly and young subjects though the fasting gall bladder volume was higher in the elderly.

Doxycycline in the treatment of rheumatoid arthritis--a pilot study

OBJECTIVE

To assess the efficacy and safety of doxycycline as a disease modifying anti-rheumatic drug (DMARD) in rheumatoid arthritis (RA) and compare it with methotrexate, a standard DMARD.

MATERIAL AND METHODS

A single (assessor) blind prospective study with 15 patients of RA randomized to doxycycline and 14 to methotrexate. Baseline disease characteristics were similar in both groups.

RESULTS

All disease activity measures studied viz. tender and swollen joint counts, physician and patient global assessment, visual analogue pain scale, health assessment questionnaire and ESR improved in both the treatment groups after six months of treatment. The difference between doxycycline and methotrexate was not statistically significant. No major side effects necessitating drug withdrawal were reported from either group. The side effects were few and mostly gastrointestinal.

CONCLUSION

Doxycycline is a safe disease modifying drug in RA whose effect is sustained at six months. It compared favourably with methotrexate over a six month follow up.

Fasciolopsiasis--a persisting problem in eastern U.P.--a case report

Fasciolopsiasis, or infection by the intestinal fluke, Fascilopsis buski, is endemic in the eastern states of our country. While it is by no means a rarity, especially in the rural set up, awareness regarding this common parasitic infestation is still a much-needed entity. The importance of a strong degree of suspicion and early diagnosis cannot be over emphasised, if a successful campaign is to be launched in its control. With this as our central theme, we proceed to report a case of and unsually heavy Fasciolopsis buski infection in our hospital, which had failed to be diagnosed in a semi urban setup in UP.

Role of doctors in prevention of torture

Torture is taking place since time immemorial. Doctors can take important part in elimination of this social evil. Torture is deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons to force another person or torture victim to make confession or giving information. Torture happens to occur in 3 forms--physical, mental and/or sexual. Doctors working in prisons, police or paramilitary/military forces are most likely to confront with torture and they should follow the medical ethics, codes and conventions in true sense. MCI, IMA, WMA should play their role in educating, motivating and supporting doctors in confronting torture. NHRC and IMA should co-operate each other to protect human rights.

Muscle response to the twin-block appliance: an electromyographic study of the masseter and anterior temporal muscles

An electromyographic study was performed on 10 young growing girls in the age group of 9 to 12 years with Class II Division 1 malocclusion and retruded mandible, who were under treatment with Twin-block appliances. Bilateral EMG activity of elevator muscles of the mandible (ie, anterior temporalis and masseter) was monitored longitudinally with bipolar surface electrodes to determine changes in postural, swallowing, and maximal voluntary clenching activity during an observation period of 6 months. The changes were noted at the start of treatment (0 month), within 1 month of Twin-block insertion, at the end of 3 months, and at the end of 6 months. The results revealed a significant increase in postural and maximal clenching EMG activity in masseter (P <.01) and a numeric increase in anterior temporalis activity during the 6 month period of treatment. The increased electromyographic activity can be attributed to an enhanced stretch (myotatic) reflex of the elevator muscles, contributing to isometric contractions. The main force for Twin-block treatment appears to be provided through increased active tension in the stretched muscles (motor unit stimulation) and from initiation of myotatic reflex activity and not through passive tension (viscoelastic properties) of jaw muscles. The results of this study reaffirm the importance of full-time wear for functional appliances to exert their maximum therapeutic effect by way of neuromuscular adaptation.

A prospective study of Lyme arthritis in north India

Twenty seven patients presenting with mono/oligoarticular disease of unknown etiology were prospectively screened for Lyme arthritis. In addition, 12 healthy blood bank donors, 25 individuals with rheumatoid arthritis (disease controls), and 20 deer handlers and veterinarians were also screened for IgG antibodies to Borrelia burgdorferi. Only one patient tested borderline positive for antibodies to B. burgdorferi (more likely false positive). None of the healthy subjects, disease controls or occupationally exposed individuals exhibited serological evidence of exposure to B. burgdorferi. Screening for Lyme disease may not be warranted while investigating mono/oligoarthritides of unknown etiology in this part of the country.

Intravascular hemolysis in aluminium phosphide poisoning

Intravascular hemolysis is most often secondary to exposure to a variety of drugs or infections, and usually occurs in patients who are deficient in glucose-6-phosphate dehydrogenase (G-6-PD) enzyme. Aluminium phosphide, a fumigant widely used in India, has been reported to produce intravascular hemolysis in only one patient who also had concomitant G-6-PD deficiency. This report describes the occurrence of intravascular hemolysis with aluminium phosphide poisoning in a patient with normal G-6-PD levels. This is of significance as jaundice in patients with this poisoning is often attributed to hepatic damage alone.