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Singh T, Padubidri JR, Ks A, Rao SJ, Manoj MA. 500 bee stings in a single fatal encounter. Med Leg J 2024:258172241241463. [PMID: 38872238 DOI: 10.1177/00258172241241463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Incidences of multiple bee stings have been increasing globally; the substantial amount of bee venom injected in such incidents can result in anaphylactic shock, rhabdomyolysis and renal failure, proving fatal in some cases. While anaphylactic reactions are more common and have established treatment protocols, inflammatory response induced by the venom demands a tailored approach. Here we report a case of a 70-year-old male in India who succumbed from approximately 500 bee stings. Based on our literature review, this case stands out as one of the first reported fatalities caused by 500 bee stings in our country. The unidentified species of bees in this case makes management of such bee venom-related toxic reactions more difficult. This report emphasises the importance of prompt and appropriate interventions.
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Affiliation(s)
- Tanya Singh
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, India
| | - Jagadish R Padubidri
- Department of Forensic Medicine and Toxicology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Akshath Ks
- Department of Paediatrics, SNR District Hospital, Kolar, India
| | - Sowmya J Rao
- Department of Oral Pathology, Sharavathi Dental College, Shimoga, India
| | - Matthew A Manoj
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, India
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2
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Pillur Tamilarasu K, Shankar T, Kabi A. Unusual case of recurrent hypoglycaemia in multiple bee sting envenomation. BMJ Case Rep 2021; 14:14/7/e242440. [PMID: 34312127 PMCID: PMC8314743 DOI: 10.1136/bcr-2021-242440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A bee sting can result in allergic and toxin-mediated local manifestations like pain, swelling, redness and itching to serious systemic effects like acute kidney injury (AKI), pancreatitis, Kounis syndrome and stroke. Melittin and phospholipase A2, which make up 62% of honeybee venom, have vasoactive, haemolytic properties causing severe AKI. Its role in lowering blood glucose in diabetics is an interesting research topic. We report an elderly herdsman, a known diabetic on irregular oral hypoglycaemic drugs, who presented with altered mental status due to hypoglycaemia. On further prodding, a recent multiple bee sting attack 5 days ago was found which was followed by altered coloured urine for 2 days for which no medical attention was sought. Additional analyses revealed reticulocytosis, azotemia and high serum creatine phosphokinase. The patient was treated with dextrose infusion, antihistamines, fluids and haemodialysis. Renal failure resolved completely and the patient was discharged in a stable condition.
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Affiliation(s)
| | - Takshak Shankar
- Emergency Medicine, All India Institute of Medical Sciences-Rishikesh, Dehradun, Uttarakhand, India
| | - Ankita Kabi
- Emergency Medicine, All India Institute of Medical Sciences-Rishikesh, Dehradun, Uttarakhand, India
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3
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Rauf A, Vijayan A, Hashitha VM, John S, Peringat J. Rhabdomyolysis and acute kidney injury following multiple bee stings in a child: A case report. JOURNAL OF PEDIATRIC CRITICAL CARE 2021. [DOI: 10.4103/jpcc.jpcc_38_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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Chauhan K, Shandilya N. An interesting story of intravascular hemolysis but normal haptoglobin and bilirubin levels. JOURNAL OF CLINICAL SCIENCES 2020. [DOI: 10.4103/jcls.jcls_76_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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5
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Ezhilnilavan S, Priyamvada PS, Srinivas BH, Satish H, Parameswaran S. Acute tubulointerstitial nephritis following hymenopteran stings. Postgrad Med J 2018; 94:418-420. [PMID: 29626057 DOI: 10.1136/postgradmedj-2018-135608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/04/2022]
Affiliation(s)
- S Ezhilnilavan
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - P S Priyamvada
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - B H Srinivas
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - H Satish
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - S Parameswaran
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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6
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Diniz-Sousa R, Kayano AM, Caldeira CA, Simões-Silva R, Monteiro MC, Moreira-Dill LS, Grabner FP, Calderon LA, Zuliani JP, Stábeli RG, Soares AM. Biochemical characterization of a phospholipase A 2 homologue from the venom of the social wasp Polybia occidentalis. J Venom Anim Toxins Incl Trop Dis 2018; 24:5. [PMID: 29467796 PMCID: PMC5815181 DOI: 10.1186/s40409-018-0143-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/19/2018] [Indexed: 12/28/2022] Open
Abstract
Background Wasp venoms constitute a molecular reservoir of new pharmacological substances such as peptides and proteins, biological property holders, many of which are yet to be identified. Exploring these sources may lead to the discovery of molecules hitherto unknown. This study describes, for the first time in hymenopteran venoms, the identification of an enzymatically inactive phospholipase A2 (PLA2) from the venom of the social wasp Polybia occidentalis. Methods P. occidentalis venom was fractioned by molecular exclusion and reverse phase chromatography. For the biochemical characterization of the protein, 1D and 2D SDS-PAGE were performed, along with phospholipase activity assays on synthetic substrates, MALDI-TOF mass spectrometry and sequencing by Edman degradation. Results The protein, called PocTX, was isolated using two chromatographic steps. Based on the phospholipase activity assay, electrophoresis and mass spectrometry, the protein presented a high degree of purity, with a mass of 13,896.47 Da and a basic pI. After sequencing by the Edman degradation method, it was found that the protein showed a high identity with snake venom PLA2 homologues. Conclusion This is the first report of an enzymatically inactive PLA2 isolated from wasp venom, similar to snake PLA2 homologues.
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Affiliation(s)
- Rafaela Diniz-Sousa
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil.,3Postgraduate Program in Experimental Biology (PGBIOEXP), Federal University of Rondônia (UNIR), Porto Velho, RO Brazil.,São Lucas University Center (UniSL), Porto Velho, RO Brazil
| | - Anderson M Kayano
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Cleópatra A Caldeira
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil.,5Postgraduate Program in Biodiversity and Biotechnology, Bionorte Network, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Rodrigo Simões-Silva
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Marta C Monteiro
- 6School of Pharmacy, Federal University of Pará (UFPA), Belém, PA Brazil
| | - Leandro S Moreira-Dill
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Fernando P Grabner
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,São Lucas University Center (UniSL), Porto Velho, RO Brazil
| | - Leonardo A Calderon
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Juliana P Zuliani
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil
| | - Rodrigo G Stábeli
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,7Department of Medicine, UFSCar, São Carlos, Center of Translational Medicine, Fiocruz - SP, and School of Medicine of Ribeirão Preto, University of São Paulo (USP), São Paulo, Brazil
| | - Andreimar M Soares
- Center for the Study of Biomolecules Applicable to Health (CEBio), Oswaldo Cruz Foundation - Rondônia (Fiocruz - Rondônia), Porto Velho, RO Brazil.,2Department of Medicine, Federal University of Rondônia (UNIR), Porto Velho, RO Brazil.,São Lucas University Center (UniSL), Porto Velho, RO Brazil
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7
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Florea A, Puică C, Hamed S, Tilinca M, Matei H. Histopathological and ultrastructural changes experimentally induced by bee venom in seminiferous epithelium via structural-functional alteration of Sertoli cells. Micron 2017; 102:1-14. [PMID: 28830057 DOI: 10.1016/j.micron.2017.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/29/2017] [Accepted: 07/29/2017] [Indexed: 12/13/2022]
Abstract
We tested here the ability of bee venom (BV) to interfere with spermatogenesis in rats in two experimental conditions. The histopathological changes were assessed with brightfield microscopy using a novel staining technique, based on methylene blue, orange G and ponceau xylidine. Transmission electron microscopy was also used to identify fine subcellular changes. BV injection for 30days in daily doses of 700μg BV/kg resulted in reducing testicular weight, along with significant larger diameters of seminiferous tubules and reduced number of Sertoli cells (SCs). SCs were vacuolated, detached from the basement membrane, many necrosed, leading to the basement membrane denudation. Germ cells layers were separated by empty spaces conferring a rarefied aspect to the tissue, and spermatids were detached into lumen. Thus, the seminiferous epithelium was significantly thinned. Many Leydig cells (LCs) were in a necrotic state, with disrupted plasma membrane and without smooth endoplasmic reticulum. The acute treatment with a single LD50 of 62mgBV/kg, was followed by focal disruptions of the basement membrane and localized areas of necrosis, mainly affecting the SCs. Most of the observed SCs as well as some spermatogonia were highly vacuoled, empty spaces being observed within the epithelium. The SCs count was significantly decreased. Spermatids had also the tendency of separation from the SCs, and the significant larger diameter of the tubules found was associated with a thicker epithelium. Many LCs were necrosed, with disrupted plasma membrane, swollen mitochondria, no endoplasmic reticulum and implicitly showing rarefied cytoplasm. We concluded that BV was a testicular toxicant affecting both the LCs and the seminiferous tubules. The SCs cells represented the primary target site of BV whose effects were next extended upon the germ cells. In all cells, BV triggered unspecific degenerative changes that could impaire spermatogenesis. The present study also proposes an alternative staining technique very useful in assessing the histopathological aspects of spermatogenesis.
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Affiliation(s)
- Adrian Florea
- Department of Cell and Molecular Biology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania.
| | - Constantin Puică
- Department of Physiology, Institute of Biological Research, 48 Gheorgh Bilaşcu St., 400015 Cluj-Napoca, Romania
| | - Sami Hamed
- Department of Cell and Molecular Biology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania
| | - Mariana Tilinca
- Department of Cellular and Molecular Biology, Faculty of Medicine, University of Medicine and Pharmacy, 38 Gheorghe Marinescu St., 540139 Târgu-Mureş, Romania
| | - Horea Matei
- Department of Cell and Molecular Biology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania
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8
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Cervellin G, Comelli I, Benatti M, Sanchis-Gomar F, Bassi A, Lippi G. Non-traumatic rhabdomyolysis: Background, laboratory features, and acute clinical management. Clin Biochem 2017; 50:656-662. [PMID: 28235546 DOI: 10.1016/j.clinbiochem.2017.02.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 12/11/2022]
Abstract
Rhabdomyolysis is a relatively rare condition, but its clinical consequences are frequently dramatic in terms of both morbidity and mortality. Although no consensus has been reached so far about the precise definition of this condition, the term rhabdomyolysis describes a rapid breakdown of striated, or skeletal, muscle. It is hence characterized by the rupture and necrosis of muscle fibers, resulting in release of cell degradation products and intracellular elements within the bloodstream and extracellular space. Notably, the percentage of patients with rhabdomyolysis who develop acute kidney injury, the most dramatic consequence, varies from 13% to over 50% according to both the cause and the clinical and organizational setting where they are diagnosed. Despite direct muscle injury (i.e., traumatic rhabdomyolysis) remains the most common cause, additional causes, frequently overlapping, include hypoxic, physical, chemical or biological factors. The conventional triad of symptoms includes muscle pain, weakness and dark urine. The laboratory diagnosis is essentially based on the measurement of biomarkers of muscle injury, being creatine kinase (CK) the biochemical "gold standard" for diagnosis, and myoglobin the "gold standard" for prognostication, especially in patients with non-traumatic rhabdomyolysis. The essential clinical management in the emergency department is based on a targeted intervention to manage the underlying cause, combined with infusion of fluids and eventually sodium bicarbonate. We will present and discuss in this article the pathophysiological and clinical features of non-traumatic rhabdomyolysis, focusing specifically on Emergency Department (ED) management.
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Affiliation(s)
| | - Ivan Comelli
- Emergency Department, Academic Hospital of Parma, Parma, Italy
| | - Mario Benatti
- Emergency Department, Academic Hospital of Parma, Parma, Italy
| | - Fabian Sanchis-Gomar
- NYU Langone Medical Center, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, USA; Department of Physiology, Faculty of Medicine, University of Valencia and Fundación Investigación Hospital Clínico Universitario de Valencia, Instituto de Investigación INCLIVA, Valencia, Spain
| | - Antonella Bassi
- Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
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9
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Sitprija V, Sitprija S. Animal toxins and renal ion transport: Another dimension in tropical nephrology. Nephrology (Carlton) 2017; 21:355-62. [PMID: 26421422 DOI: 10.1111/nep.12633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/10/2015] [Accepted: 09/24/2015] [Indexed: 12/31/2022]
Abstract
Renal vascular and tubular ion channels and transporters involved in toxin injury are reviewed. Vascular ion channels modulated by animal toxins, which result in haemodynamic alterations and changes in blood pressure, include ENaC/Degenerin/ASIC, ATP sensitive K channels (KATP ), Ca activated K channels (Kca) and voltage gated Ca channels, mostly L-type. Renal tubular Na channels and K channels are also targeted by animal toxins. NHE3 and ENaC are two important targets. NCC and NKCC may be involved indirectly by vasoactive mediators induced by inflammation. Most renal tubular K channels including voltage gated K channels (Kv1), KATP , ROMK1, BK and SK are blocked by scorpion toxins. Few are inhibited by bee, wasp and spider venoms. Due to small envenoming, incomplete block and several compensatory mechanisms in renal tubules, serum electrolyte charges are not apparent. Changes in serum electrolytes are observed in injury by large amount of venom when several channels or transporters are targeted. Envenomings by scorpions and bees are examples of toxins targeting multiple ion channels and transporters.
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Affiliation(s)
- Visith Sitprija
- Queen Saovabha Memorial Institute, Mahidol University, Bangkok, Thailand
| | - Siravit Sitprija
- Department of Biology, Faculty of Science, Mahidol University, Bangkok, Thailand
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10
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Gupta PN, Kumar BK, Velappan P, Sudheer MD. Possible complication of bee stings and a review of the cardiac effects of bee stings. BMJ Case Rep 2016; 2016:bcr-2015-213974. [PMID: 27803018 DOI: 10.1136/bcr-2015-213974] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report the case of a patient who, ∼3 weeks after multiple bee stings, developed a prolonged heart block, syncope and cardiac arrest. This required a temporary pacemaker to be implanted, which was later replaced with a permanent pacemaker. An ECG taken following surgery for a fractured humerus 6 years earlier was reportedly normal. The patient had been a rubber tapper who walked ∼1.5 km/day, but after the bee attack he was no longer able to walk or get up from the bed without experiencing syncope. We presume that the bee venom caused these signs, as well as the resulting heart block, which persisted long after the bee sting had subsided. Since his coronary angiogram was normal we believe he had a Kounis type involvement of the cardiovascular system, namely profound coronary spasm that caused complete heart block that did not recover. Another probable reason for the complete heart block could have been that the bees had consumed the pollen of a rhododendron flower, causing 'grayanotoxin' poisoning and severe heart block. The other effects of bee sting are discussed briefly.
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Affiliation(s)
- Prabha Nini Gupta
- Department of Cardiology, Medical College Hospital, Trivandrum, Trivandrum, Kerala, India
| | - B Krishna Kumar
- Department of Cardiology, Medical College Hospital, Trivandrum, Trivandrum, Kerala, India
| | - Praveen Velappan
- Department of Cardiology, Medical College Hospital, Trivandrum, Trivandrum, Kerala, India
| | - M D Sudheer
- Department of Cardiology, Medical College Hospital, Trivandrum, Trivandrum, Kerala, India
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[Mortal poisoning by bee stings in a child: Study of a case observed in the regional hospital of Maradi (Niger)]. ACTA ACUST UNITED AC 2016; 109:325-328. [PMID: 27738911 DOI: 10.1007/s13149-016-0506-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 05/03/2016] [Indexed: 11/26/2022]
Abstract
We report a fatal case due to a massive attack by a swarm of bees in a nine-year-old child. The accident was fatal because of two aggravating factors: the cephalic location and the large number of stings (about 300). Complications were coagulopathy, anemia, hemorrhage, coma, and oligoanuria. Support was symptomatic at a facility second level. The outcome was fatal within 14 days. In view of the encountered difficulties, we recommend to build written protocols for the management of envenomation in any health training reference.
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12
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Affiliation(s)
- Bindu T Nair
- Department of Paediatrics, Army College of Medical Sciences, Delhi Cantt, New Delhi, India
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13
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Dharod MV, Patil TB, Deshpande AS, Gulhane RV, Patil MB, Bansod YV. Clinical predictors of acute kidney injury following snake bite envenomation. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:594-9. [PMID: 24350071 PMCID: PMC3842700 DOI: 10.4103/1947-2714.120795] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Snake bite envenomation is a major public health concern in developing countries. Acute kidney injury (AKI) is as important cause of mortality in patients with vasculotoxic snake bite. Aims: This study was to evaluate the clinical profile of snake bite patients and to determine the predictors of developing AKI following snake bite. Materials and Methods: Two hundred and eighty-one patients with snake envenomation were included. Eighty-seven patients developed AKI (Group A) and 194 (Group B) did not. History, examination findings and investigations results were recorded and compared between the two groups. Results: In group A, 61 (70.11%) patients were male and in group B, 117 (60.30%) patients were male. Out of 281 patients, 232 had cellulitis, 113 had bleeding tendencies, 87 had oliguria, 76 had neuroparalysis, and 23 had hypotension at presentation. After multivariate analysis, bite to hospital time (P = 0.016), hypotension (P = 0.000), albuminuria (P = 0.000), bleeding time (P = 0.000), prothrombin time (P = 0.000), hemoglobin (P = 0.000) and total bilirubin (P = 0.010) were significant independent predictors of AKI. Conclusions: AKI developed in 30.96% of patients with snake bite, leading to mortality in 39.08% patients. Factors associated with AKI are bite to hospital time, hypotension, albuminuria, prolonged bleeding time, prolonged prothrombin time, low hemoglobin and a high total bilirubin.
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Affiliation(s)
- Mrudul V Dharod
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Tushar B Patil
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Archana S Deshpande
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Ragini V Gulhane
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Mangesh B Patil
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Yogendra V Bansod
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
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