Recurrent lymphocytic hypophysitis in a woman 27 years after subtotal adrenalectomy for hypercortisolism possibly of autoimmune origin

Lymphocytic hypophysitis commonly occurs in females in peripartum period but several unusual presentations have been reported. Here we report a rare case of recurrent lymphocytic hypophysitis in a woman who had subtotal adrenalectomy for hypercortisolism 27 years back. Polyglandular autoimmune endocrinopathy with an uncommon combination of Cushing's syndrome and recurrent hypophysitis is a strong possibility in this case. Treatment with steroids has been found to have beneficial effect.

Phenotypic characteristics of clinical isolates of Klebsiella pneumoniae & evaluation of available phenotypic techniques for detection of extended spectrum beta-lactamases

BACKGROUND & OBJECTIVES

Identifying organisms that harbour extended spectrum beta lactamases (ESBLs) is a major challenge for a diagnostic clinical microbiology laboratory. Wide variety of ESBLs produced and lack of a sensitive phenotypic method for their detection make the detection of ESBLs difficult and is responsible for under-recognition. The present study was undertaken to evaluate phenotypic characteristics, initial screening tests and established confirmatory phenotypic methods for detection of ESBLs Klebsiella pneumoniae isolates prevalent in a hospital in north India.

METHODS

One hundred, non-repeat clinical isolates of K. pneumoniae collected over a period of six months were included in the study. Susceptibilities of the isolates to 20 different antimicrobial agents were determined. Agar dilution and broth dilution methods were used to determine minimum inhibitory concentrations (MICs) of ceftazidime (CAZ) and cefotaxime (CTX). CAZ and CTX were used with and without clavulanic acid to detect ESBL harbouring isolates. Using agar dilution and broth dilution, MIC reduction of two and three doubling dilutions were evaluated as a criterion for ESBL harbouring isolates. Standard double disk synergy test (DDST) with disks placed at 30 mm and modified DDST with disks placed at 16 mm center-to-center distance, using at least two different third generation cephalosporins and combined disk method were also performed to detect ESBL harbouring isolates.

RESULTS

Multi-drug resistance (resistance to three or more antimicrobials of different classes) was found among 94 per cent of the isolates. Pooling the results of all the three confirmatory techniques MIC reduction of >3 doubling dilutions using broth dilution method (using CTX and CAZ), combined disk method [(using CTX, ceftriaxone [(CRO), CAZ and aztreonam)] and standard DDST (using CTX, CRO, CAZ and aztreonam), revealed as many as 87 per cent of the isolates as ESBL producers. CTX had greater sensitivity in identifying isolates that harboured ESBLs. Modified DDST using CTX was as sensitive method as broth dilution method and combined disk method in detecting ESBL harbouring isolates. MIC reduction technique using agar dilution method and standard DDST had lowest overall sensitivity in detecting ESBLs.

INTERPRETATION & CONCLUSION

Modified DDST using at least two different third generation cephalosporins was considered to be the best technique for detection of ESBL producing K. pneumoniae at our hospital. MIC reduction test with >2 doubling dilution reduction in MICs was found to be a better criterion than the presently recommended >3 doubling dilution reduction. For screening of potential ESBL producers, MIC determination using agar dilution was as good as that using broth dilution method. However, while performing MIC reduction test agar dilution method was found highly unreliable for detection of ESBL harbouring isolates.

Discrimination of glaucomatous optic neuropathy by digital stereoscopic analysis

PURPOSE

To evaluate the diagnostic power of a novel digital stereoscopic imaging system in the diagnosis of glaucomatous optic neuropathy.

DESIGN

Prospective cross-sectional analysis of the diagnostic accuracy of digital stereoscopic optic disc analysis in the diagnosis of glaucomatous optic neuropathy exhibiting mild to moderate field loss.

PARTICIPANTS

Fifty-two patients with open-angle glaucoma and 54 normal individuals were recruited. The presence of a reproducible visual field loss characteristic of glaucoma was used as the reference standard for the presence of glaucoma independent of the optic nerve head appearance. Patients were excluded if the optic disc, fundus, or visual field indicated other disease. One eye from each patient and individual was included in the study, the eye with the least field loss and a randomly designated normal eye, respectively.

METHODS

Simultaneous stereoscopic optic disc photography was performed on each specified eye. Three experienced observers viewed the resultant stereoscopic image of each nerve head using a Z screen, recorded a subjective clinical diagnosis, and undertook digital stereoscopic planimetry. Separate linear regression analysis was performed, post hoc, from the planimetric results for each observer of the logarithm of neuroretinal rim (NRR) against optic disc area derived from each normal eye. Eyes with NRR areas below the 95th prediction interval of the normal cohort were then classified as glaucomatous.

MAIN OUTCOME MEASURES

Sensitivity and specificity for the detection of glaucomatous optic neuropathy.

RESULTS

With subjective stereoscopic analysis, sensitivity for glaucoma detection among the 3 observers was 80.8%, 76.9%, and 90.4%, with respective specificities of 94.4%, 79.6%, and 79.6%. Regression analysis of the NRR in 30 degrees segments gave sensitivities between 69.2% and 80.8% and specificities between 83.3% and 90.7%. A combination of the subjective and quantitative analysis did not significantly improve discrimination.

CONCLUSIONS

The subjective analysis of digital stereoscopic images provides a useful method for the discrimination of normal and glaucomatous optic nerves. Planimetric analysis does not significantly improve the diagnostic precision of this technique.

Myelodysplastic syndrome with erythroid hypoplasia

The incidence of myelodysplastic syndrome (MDS) with erythroid hypoplasia/aplasia is probably underestimated because in most patients it is mistaken for acquired pure red blood cell aplasia. This report describes three children who fulfilled the criteria for MDS with erythroid hypoplasia/aplasia. All these patients had transfusion dependent anaemia, reticulocytopenia, erythroid hypoplasia/aplasia, severe dysgranulopoiesis, and dysmegakaryopoiesis.

Septic arthritis due toArcanobacterium haemolyticum

Diphtheroids or "coryneform" bacilli are usually considered to be nonpathogenic "normal flora" of human skin and mucous membranes. Because bacterial cultures are frequently contaminated with these organisms the correct diagnosis and treatment may be delayed by the failure to recognize serious infections caused by them. Few confirmed cases of orthopaedic infections due to Arcanobacterium haemolyticum infection have been reported, partly because of inadequate identification of this bacterium. We report a case of septic arthritis due to A. haemolyticum.

Referrals for cataract surgery: variations between different geographic areas within a Welsh Health Authority

AIM

The aim of the study was to identify variations in cataract presentation within three different eye units in a single health authority and to identify any correlation between cataract presentation and social deprivation indices. We also compared our patient profile and results with the UK National Cataract Audit Statistics.

METHODS

It was a prospective multicentre questionnaire-based project involving three hospitals: Cardiff Eye Unit--University Hospital of Wales (UHW), Royal Glamorgan Hospital--Llantristant (RGH), and Prince Charles Hospital--Merthyr Tydfil (PCH). Demographic, clinical, and socioeconomic data were collected in patients undergoing cataract surgery. Patients were also asked to fill in the questionnaire based on Berth-Petersen Visual Function Index (VF-14) indicating difficulty in performing daily living activities.

RESULTS

A total of 112 patients were recruited in the study. Demographics were similar to National Cataract Audit. However, the percentage of patients with poor visual acuity (less than 6/60) at the time of surgery was greater at all the three hospitals compared to the national statistics. Among the three hospitals at South Wales, PCH had the lowest visual acuity in both listed and fellow eye and the lowest VF-index. Both the outpatient and surgery waiting times were longest at PCH. The population at PCH also visited their optician least frequently.

CONCLUSION

Our results show significant variation in cataract presentation between the three eye units within a single Health Authority. These variations correlate well with social deprivation indices and poor use of Optometric services. Local policies are needed to redress these inequalities and raise public and professional awareness of causes of poor sight in the elderly population.

Detection of clindamycin susceptibility in macrolide resistant phenotypes of Staphylococcus aureus

The present study aimed at in vitro detection of macrolide resistant phenotypes of methicillin resistant Staphylococcus aureus (MRSA) and interpretation of susceptibility tests to guide therapy. The study included 25 MRSA strains that were resistant to erythromycin and clindamycin, 25 MRSA strains that were sensitive to both erythromycin and clindamycin and 100 MRSA isolates which displayed erythromycin resistant but clindamycin susceptible phenotype. Erythromycin and clindamycin double disc susceptibility testing was done to detect inducible clindamycin resistance. Dilution susceptibility testing for clindamycin and erythromycin alone and in combination was performed for all 150 strains. Seventy-six strains showed blunting around clindamycin disc (inducible resistance). After induction with erythromycin, minimum inhibitory concentration (MIC) of clindamycin was noticed to rise from at least 16 to 256 g/mL in iMLSB phenotypes indicating inducible resistance. The detailed result analysis suggests the possible role of clindamycin in treatment of some of the erythromycin resistant isolates (non inducible), as there are multiplicity of resistance mechanisms and diversity of phenotypic expressions.

Pathology teach and tell: neonatal hemochromatosis with massive hepatic necrosis

Neonatal hemochromatosis (NH) is an uncommon disorder clinicopathologically defined by severe liver disease of intrauterine onset associated with extrahepatic siderosis that spares reticuloendothelial elements. NH phenotypically is a similar disorder to hereditary hemochromatosis. However, its extremely early onset of liver failure makes it notably unique. Massive liver necrosis in the newborn is a rare occurrence, but whenever present hemochromatosis should be considered in the differential diagnosis. Herein, we report a case of neonatal hemochromatosis that had massive hepatic necrosis with sparing only little parenchyma. The outcome was fatal within the first month of life.

Comparison of laser interferometry and ultrasound A-scan in the measurement of axial length

AIM

Laser interferometry is a new, non-contact technique for the measurement of axial length. In this study we compared measurements of axial length obtained with this technique with those obtained with ultrasound (A-scan). The reproducibility and examiner-dependency of the two methods were also analysed.

METHODS

Patients presenting at the cataract assessment clinic were invited to participate in the study. Axial length measurements were obtained both by contact ultrasound (A-scan) and by non-contact laser interferometry (IOLMasterTM V1.1, Carl Zeiss, Jena, Germany). Intraocular lens powers were calculated using both sets of measurements. The coefficient of variation served as a measure of reproducibility.

RESULTS

A total of 100 eyes in 100 patients were evaluated after informed consent had been obtained. Although estimates of axial length obtained with the two techniques were highly correlated, axial lengths obtained with the contact method (mean 23.35 mm, SD 1.81 mm) were consistently lower than those obtained with the non-contact method (mean 23.55 mm, SD 1.76 mm) and the difference was statistically significant (p < 0.001). The coefficient of variation was lower with laser interferometry (0.1%) than with the ultrasound technique (0.49%).

CONCLUSIONS

Different estimates of axial length are obtained using contact and non-contact techniques, with the latter producing consistently higher measurements than the former. Laser interferometry provides more reproducible results that should improve the accuracy of measurements of axial length in the clinical setting.

Changing trends in bacteriology of burns in the burns unit, Delhi, India

A retrospective study of bacterial isolates from the wounds of patients admitted to burns unit, was undertaken at Guru Tegh Bahadur Hospital, University College of Medical Sciences, Delhi, India, over a period of 5 years between July 1997 and April 2002. The study compared the results obtained with the previous 5 years data (June 1993-June 1997) from the same unit to determine the changing patterns and emerging trends of bacterial isolates and their antimicrobial susceptibilities. Pseudomonas species (31%) and Staphylococcus aureus (22%) were the most common pathogens followed by Klebsiella species (19%). Multi-drug resistant (MDR) Acinetobacter species (9%) have emerged as an important nosocomial pathogen in our burn unit. Most of the gram-negative isolates obtained were found to be multi-drug resistant and 61% of the tested isolates were extended spectrum beta-lactamase (ESBL) producers. Concomitant resistance to penicillin and aminoglycosides was observed in 61% of Enterococcus fecalis isolates. When compared with the results of previous 5 years (June 1993-June 1997) Pseudomonas spp. was still the commonest pathogen in the burns unit. However, isolation of this organism and other gram-negative organisms has decreased in comparison to previous years. The incidence of antimicrobial resistance has markedly increased over the past years resulting in limitation of therapeutic options.

Reversible peripheral neuropathy in idiopathic hypoparathyroidism

We describe a 40-year-old male with idiopathic hypoparathyroidism presenting with tetany, proximal weakness, signs of hypocalcaemia including Chvostek and Trousseau's and diminished tendon reflexes in the upper and lower limbs. Electrophysiological studies revealed a sensory-motor neuropathy, predominantly axonal as evidenced by decreased CMAP amplitudes, with normal distal latencies-velocites, except for median nerve where a prolonged distal latency was observed. Serial nerve conduction studies were performed at repeated intervals for 2 years, while he received treatment for hypoparathyroidism (calcium and vitamin D supplementation). A progressive improvement in neuropathy both clinical and on electrophysiological studies was observed. Occurrence of peripheral neuropathy in hypocalcaemic states such as hypoparathyroidism and its reversibility after normalization of calcium homeostasis lend proof to the role of critical Ca2+ ion concentration in the normal functioning of the peripheral axons.

A rare foreign body on penis leading to incarceration

Foreign body on penis is usually put himself or by his female partner by adults for sexual gratification and in children as an innocent childish play. We have managed a 10 years shepherd who put on a bark of tree with successful outcome which is not being reported in literature.

Conversion of atrial fibrillation by the experimental antiarrhythmic drug tedisamil in two canine models

INTRODUCTION

Tedisamil is an experimental bradycardic agent possessing action potential-prolonging effects. It has been proven effective in terminating ventricular arrhythmias in several animal models and atrial flutter in a conscious dog model. There are no reports to date evaluating tedisamil's efficacy in terminating atrial fibrillation (AF).

METHODS AND RESULTS

Two different canine models of AF were used. One group of dogs (n = 6) was subjected to 28 days of chronic fibrillatory pacing at 50 Hz using an implantable neural stimulator. Sustained AF was achieved in all dogs within 14 days of initiating pacing. A second set of dogs (n = 5) had AF induced via bilateral vagal stimulation. Tedisamil 1 mg/kg was 100% effective in terminating AF in both models. Cardioversion was associated with a statistically significant prolongation of the fibrillatory cycle length immediately before return to normal sinus rhythm in both models. A dose-response trial was performed in the vagal AF group as well as in a second group of three dogs that underwent chronic fibrillatory pacing. The efficacy of tedisamil was dose dependent, with limited efficacy at 0.1 and 0.3 mg/kg intravenously in both models. Tedisamil was able to prevent reinduction of sustained AF 30 minutes after administration of 1 mg/kg in the chronic pacing model in all dogs. Side effects included minor hypersalivation in most dogs receiving the 1 mg/kg dose. No ventricular ectopy or arrhythmias were observed.

CONCLUSION

Tedisamil is effective for conversion of sustained AF to normal sinus rhythm in two different models of AF.