The Definition, Acronyms, Nomenclature, and Classification of Angioedema: AAAAI, ACAAI, ACARE, and APAACI DANCE Consensus

BACKGROUND

Angioedema (AE) manifests with intermittent, localized, self-limiting swelling of the subcutaneous and/or submucosal tissue. AE is heterogeneous, can be hereditary or acquired, occurs only once or be recurrent, with or without wheals, due to mast cell mediators, bradykinin or other mechanisms. Currently, different taxonomic systems are used, making it difficult to compare the results of studies, develop multicenter collaboration, and harmonize treatments of AE patients.

OBJECTIVE

To develop a consensus on the definition, acronyms, nomenclature, and classification of angioedema (DANCE).

METHODS

The initiative involved 91 experts from 35 countries and was endorsed by 53 scientific, medical societies, and patient organizations. A consensus was reached by online discussion and voting using the Delphi process over a period of 16 months (June 2021 to November 2022).

RESULTS

The DANCE initiative resulted in an international consensus on the definition, classification and terminology of AE. The new consensus classification features five types and endotypes of AE and a harmonized vocabulary of abbreviations and acronyms.

CONCLUSION

The DANCE classification complements current clinical guidelines and expert consensus recommendations on the diagnostic workup and treatment of AE. DANCE does not replace current clinical guidelines and expert consensus algorithms and should not be misconstrued in a way that affects reimbursement of medicines prescribed by a physician using sound clinical judgment. We anticipate that the new AE taxonomy and nomenclature will harmonize and facilitate AE research and clinical studies, thereby improving patient care.

Treatment adherence and its determinants among the rheumatic fever/rheumatic heart disease patients during COVID 19 pandemic - A cross sectional study from Chandigarh, India

Background

Rheumatic heart disease/Rheumatic fever is a non - communicable disease being a major neglected health problem. Recurrent attacks of rheumatic fever can have catastrophic outcomes, therefore regular administration of antibiotics is recommended. During COVID 19 pandemic, people were afraid to approach hospitals hence the compliance and follow up of patients were affected. This study had planned to assess the treatment adherence of patients diagnosed with rheumatic fever/rheumatic heart disease during COVID 19 pandemic and to describe the socio demographic factors, clinical characteristics. This study also determines the factors associated with the treatment adherence.

Methods

A cross sectional study was conducted among Rheumatic Fever/Rheumatic Heart Disease patients, attending Outpatient department at tertiary care hospital during COVID 19 pandemic. Mean score with confidence interval was calculated for quantitative data. P value less than 0.05 is significant.

Results

The Mean (SD) age of the study participants was 41 ± 14.17 years. Treatment adherence was found to be 94.5 percent among Rheumatic Fever/Rheumatic Heart Disease patients during COVID 19 pandemic. 89.5% of injection benzathine penicillin users had an adherence rate above 80 percent. It was found that the presence of comorbidities (Diabetes/Hypertension/both Diabetes and Hypertension) had a statistically significant association with treatment adherence.

Conclusions

Rheumatic Heart Disease is a disease of young and middle -age population affecting predominantly females. The overall adherence rate among Rheumatic Fever/Rheumatic Heart Disease patients was high. High time to maintain hospital-based registry to have follow up of patients.

Pediatric Lupus Retinopathy: A Rare Manifestation of a Grave Systemic Disorder

We describe a rare case of pediatric systemic lupus erythematosus (pSLE) and its successful management. A nine-year-old female presented with bilateral diminution of vision, fever, and rash in the malar region, chest, abdomen, back, and arms for three months. Clinical examination and multimodal imaging revealed bilateral extensive retinal vasculitis with macular edema. Laboratory investigations revealed anemia, leucopenia, positive serum antinuclear antibody (ANA), and anti-extractable nuclear antigen (ENA) antibodies. A diagnosis of pediatric lupus retinopathy was made. Ocular and systemic manifestations responded well to intense systemic immunosuppression (pulse intravenous {IV} methylprednisolone, oral prednisolone and hydroxychloroquine {HCQ}, six cycles of IV cyclophosphamide, and oral azathioprine) along with topical steroids and laser photocoagulation, over the next 10 months. Though ocular manifestations are not a part of the diagnostic criteria for SLE, they may be markers of active systemic disease. Ophthalmologists and rheumatologists must treat this complex disease in tandem in order to provide optimum patient care.

An Autopsy Case of Wiskott-Aldrich Syndrome Revealing "FDC-Only Lymphoid Follicles" in Lymphoid Tissue: A Morphologic Correlate of Defective Immune Synapse

Wiskott-Aldrich Syndrome (WAS) is an inherited disorder characterized by the classical triad of eczema, micro-thrombocytopenia, and immune deficiency. This disease affects the hematopoietic cells to a variable extent. The spectrum of clinical and laboratory data for WAS has been well described in the literature though there is a paucity of its histopathologic and immunohistochemical correlates. The current case describes the autopsy findings of this rare entity in an 8-year old male child with specific recognition of altered histology noticed in the lymphoreticular tissues. The predominant morphological finding in lymphoid tissue was atretic hyalinized germinal centers labeled as "the follicular dendritic cell (FDC)-only lymphoid follicles." Immunohistochemistry revealed a reduction in germinal-center B-cells, T-follicular helper cells, attenuated mantle zone, FDC proliferation, and paracortical plasmacytosis. This case highlights the crippled immune cell population in WAS, ultimately leading to the morphology of atretic follicles rich in FDCs.

Successful Management of Catastrophic Thrombotic Storm in a Young Boy: A Case Report From Northern India

Thrombotic storm is a rare clinical entity characterized by acute to subacute thrombosis developing at multiple sites over a few days to a few weeks. An 11-year-old boy presented with headache and facial nerve palsy. He was found to have cortical sinus venous thrombosis and was initiated on low molecular weight heparin, but rapidly progressed with thromboses involving the pulmonary arteries and deep veins of the legs. Thereafter managed on high-dose unfractionated heparin, he eventually stabilized after a hospital stay of 34 days. Genetic analysis showed potentially pathogenic variants in the factor V and stabilin-2 genes.

LINEZOLID-INDUCED MITOCHONDRIAL TOXICITY PRESENTING AS RETINAL NERVE FIBER LAYER MICROCYSTS AND OPTIC AND PERIPHERAL NEUROPATHY IN A PATIENT WITH CHRONIC GRANULOMATOUS DISEASE

PURPOSE

To report a case with unique changes in the retinal nerve fiber layer observed on optical coherence tomography in a 22-year-old patient on chronic linezolid therapy for recurrent pyogenic liver abscesses with underlying chronic granulomatous disease.

METHODS

History and clinical examination, laboratory evaluation, fluorescein angiography, and optical coherence tomography.

RESULTS

The patient presented with best-corrected visual acuity of 20/200 in the right eye and 20/125 in the left eye. He had moderate optic disk edema and superotemporal field defects bilaterally. Swept-source optical coherence tomography revealed the presence of retinal nerve fiber layer microcystic spaces. Laboratory tests showed no positive findings except for an elevated lactic acid level. Linezolid-induced optic neuropathy was suspected, and the drug was discontinued. Six weeks after termination of oral linezolid therapy, the optic disk edema and the microcystic spaces in the retinal nerve fiber layer resolved, and the best-corrected visual acuity improved to 20/50 in the right and 20/40 in the left eye, respectively.

CONCLUSION

Linezolid is a widely used antibiotic with broad-spectrum action. However, chronic use can lead to mitochondrial toxicity that may have protean manifestations. Ocular examination, particularly of the optic nerve and nerve fiber layer using multimodal imaging, is critical in diagnosing such toxicity.

Wiskott Aldrich Syndrome: A Multi-Institutional Experience From India

Background

Wiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent infections, eczema, autoimmunity, and malignancy. Over the last decade, improved awareness and better in-house diagnostic facilities at several centers in India has resulted in increased recognition of WAS. This study reports collated data across major primary immunodeficiency diseases (PID) centers in India that are involved in care of children with WAS and highlights the varied clinical presentations, genetic profile, and outcomes of patients in India.

Methods

Request to share data was sent to multiple centers in India that are involved in care and management of patients with PID. Six centers provided requisite data that were compiled and analyzed.

Results

In this multi-institutional cohort, clinical details of 108 patients who had a provisional diagnosis of WAS were received. Of these, 95 patients with 'definite WAS' were included Fourteen patients were classified as XLT and 81 patients as WAS. Median age at onset of symptoms of patients was 3 months (IQR 1.6, 6.0 months) and median age at diagnosis was 12 months (IQR 6,48 months). Clinical profile included bleeding episodes (92.6%), infections (84.2%), eczema (78.9%), various autoimmune manifestations (40%), and malignancy (2.1%). DNA analysis revealed 47 variants in 67 cases. Nonsense and missense variants were the most common (28.4% each), followed by small deletions (19.4%), and splice site defects (16.4%). We also report 24 novel variants, most of these being frameshift and nonsense mutations resulting in premature termination of protein synthesis. Prophylactic intravenous immunoglobulin (IVIg) was initiated in 52 patients (54.7%). Hematopoietic stem cell transplantation (HSCT) was carried out in 25 patients (26.3%). Of those transplanted, disease-free survival was seen in 15 patients (60%). Transplant related mortality was 36%. Outcome details were available for 89 patients. Of these, 37% had died till the time of this analysis. Median duration of follow-up was 36 months (range 2 weeks- 12 years; IQR 16.2 months- 70 months).

Conclusions

We report the first nationwide cohort of patients with WAS from India. Bleeding episodes and infections are common manifestations. Mortality continues to be high as curative therapy is not accessible to most of our patients.

Novel SERPING1 gene mutations and clinical experience of type 1 hereditary angioedema from North India

BACKGROUND

There is paucity of literature on long-term follow-up of patients with hereditary angioedema (HAE) from developing countries.

OBJECTIVE

This study was carried out to analyze the clinical manifestations, laboratory features, and genetic profile of 32 patients (21 male and 11 female) from 23 families diagnosed with HAE between January 1996 and December 2019.

METHODS

Data were retrieved from medical records of Paediatric Immunodeficiency Clinic, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

RESULTS

Median age at onset of symptoms was 6.25 years (range 1-25 years), and median age at diagnosis was 12 years (range 2-43 years). Serum complement C4 level was decreased in all patients. All patients had low C1-esterase inhibitor (C1-INH) quantitative level (type 1 HAE). SERPING1 gene sequencing could be carried out in 20 families. Of these, 11 were identified to have a pathogenic disease-causing variant in the SERPING1 gene. While 2 of these families had a previously reported mutation, remaining 9 families had novel pathogenic variants in SERPING1 gene. Because of non-availability of C1-INH therapy in India, all patients were given long-term prophylaxis (attenuated androgens or tranexamic acid (TA) or a combination of the 2). Life-threatening episodes of laryngeal edema were managed with fresh-frozen plasma (FPP) infusions. We recorded one disease-related mortality in our cohort. This happened in spite of long-term prophylaxis with stanozolol and TA.

CONCLUSIONS

We report largest single-center cohort of patients with HAE from India. Attenuated androgens, fibrinolytic agents, and FPP may be used for management of HAE in resource-limited settings.

Sun Exposure in Children: Balancing the Benefits and Harms

There is a common belief among the laity and even physicians that sun exposure is a useful source of vitamin D. However, despite the fact that sun exposure occurs almost throughout the year in India, vitamin D deficiency is widely prevalent. Although several authors have reported on the duration of sun exposure required to synthesize adequate amounts of vitamin D in the human body, they have not followed a standard and uniform protocol for measurement of sun exposure and vitamin D synthesis. For these and many other reasons, the results are difficult to interpret. The American Academy of Pediatrics (AAP) has clearly stated that infants should be protected from the sun as much as possible and vitamin D requirements should be met through diet and fortified foods rather than deliberate sun exposure. However, this recommendation is frequently ignored in clinical practice. This review aims to summarize the available literature on benefits and harm of unprotected sun exposure in infants and children with a focus on skin phototype IV to VI. Dermatologists and pediatricians in India should counsel parents about the need for sun protection, especially in fair-skinned infants and children.

Food safety and quality control: Best practices in the Indian Armed Forces

The Army Marches on its Stomach". To provide nutritious, wholesome, safe and quality food to the large Indian Armed Forces, spread over various terrains, ranging from the icy Himalayas to the burning deserts of Rajasthan or the humid jungles of the North East and over various platforms like tanks, ships and aircraft is a challenge. The major issue in this is to procure and supply the food while ensuring that it is safe and retains its quality till it is cooked. This vital part of the supply chain viz from farm to the military cook house is the responsibility of the Army Service Corps (ASC) supported by the Army Medical Corps (AMC) and the Remount and Veterinary Corps (RVC). The Food Inspection Organization of the ASC lays down the best practices to be followed in terms of inspection, sampling, analysis, dispatch and issue of both fresh and processed edible foodstuff. The Armed Forces have their own network of Composite Food Laboratories for sampling and analysis of the food items. To ensure superior quality the Defence Food Specifications are much higher than legislated by the Food Standards and Safety Authority of India (FSSAI) for the general public. This paper highlights the best practices followed to ensure food safety and quality control in the Indian Armed Forces.

An updated review on phenocopies of primary immunodeficiency diseases

Primary immunodeficiency diseases (PIDs) refer to a heterogenous group of disorders characterized clinically by increased susceptibility to infections, autoimmunity and increased risk of malignancies.

These group of disorders present with clinical manifestations similar to PIDs with known genetic defects but have either no genetic defect or have a somatic mutation and thus have been labelled as “Phenocopies of PIDs”. These diseases have been further subdivided into those associated with somatic mutations and those associated with presence of auto-antibodies against various cytokines.

In this review, we provide an update on clinical manifestations, diagnosis and management of these diseases.

Chylous ascites and podocytopathy as the presentation of childhood lupus-an unusual occurrence

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can affect virtually any organ. Chylous ascites as a presenting manifestation of SLE has been described in a handful of cases in adults. However, to the best of our knowledge this presentation has never been reported in the pediatric age group. Podocytopathy in SLE was initially considered to be a chance association. However, more recently it has been suggested that minimal change disease is not only a chance association; it is part of the lupus nephritis spectrum.

Autoantibody profile in children with Kawasaki disease on long-term follow-up: A prospective study from North India

AIM

To study the profile of autoantibodies on long-term follow-up of children with Kawasaki disease (KD).

PATIENTS AND METHODS

In this single-center observational cohort study, 50 children who had been diagnosed and treated for KD with a minimum follow-up period of 3 years were enrolled. The organ-specific autoantibodies that were assessed in the study included anti-thyroid microsomal antibody (TMA), anti-parietal cell antibody (PCA) and anti-liver kidney microsomal (LKM) antibody. The organ-nonspecific autoantibodies that were studied included anti-endothelial cell antibody (AECA), anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), anti-mitochondrial antibody (AMA) and anti-smooth muscle antibody (SMA).

RESULTS

The sample for assessment of serology was taken at a mean follow-up period of 6.41 years (±1.95 SD) after diagnosis. Autoantibodies were detected in 11/50 (22%) patients. ANA was detected in three patients, TMA was positive in seven and ANCA was positive in one.

CONCLUSIONS

These autoantibodies likely develop in children with KD during the acute stage and may persist for many years. There is no concrete evidence to suggest that these children are at increased risk of developing an autoimmune disease in the future. However, there is some justification for prolonged surveillance for development of autoimmune manifestations.

Cytomegalovirus Disease in HIV-infected Children-A Single-Centre Clinical Experience over 23 Years

BACKGROUND

Cytomegalovirus (CMV) results in significant morbidity and mortality in Human Immunodeficiency Virus (HIV)-infected individuals. There is paucity of literature on paediatric CMV disease, especially from developing countries.

METHODS

A retrospective review of records of all HIV-infected children with evidence of CMV disease was done.

RESULTS

A total of 15 children were found to have CMV disease (retinitis in all, pneumonia in two and invasive gastrointestinal disease in one). Median CD4+ T cell count and percentage at diagnosis of CMV disease was 64.5 cells/µl and 3.6%, respectively. Intravenous ganciclovir was used in patients with active CMV disease. Of the 15 children, three died while two were lost to follow-up. Symptomatic patients had poor visual outcome and almost all children who were diagnosed on active screening attained normal vision.

CONCLUSION

Retinitis is the most common CMV disease in HIV-infected children. Early detection by active screening and initiation of systemic ganciclovir reduces the morbidity.

Approach to a Child with Primary Immunodeficiency Made Simple

Primary immunodeficiency disorders (PIDs) are a group of disorders affecting the capability to fight against infection. These include defects in T cells and B cells affecting cell-mediated and humoral immunity, respectively, combined humoral and cell-mediated immunodeficiency, defects in phagocytosis, complement defects, and defects in cytokine or cytokine signalling pathways which are detrimental for immune function. Depending upon the type and severity, age at onset of symptoms can vary from neonatal period to late childhood. Clinically, this group of disorders can involve any organ system of an individual such as respiratory system, gastrointestinal system, skin and mucous membrane, bone and joints, endocrine organs, and nervous system. Common dermatological manifestations include eczema, warts, molluscum contagiosum, mucocutaneous candidiasis, recurrent nonhealing ulcers, skin abscesses, erythroderma, petechiae, and nail changes. The common skin manifestations of various PIDs include eczema (seen in Wiskott-Aldrich syndrome and autosomal dominant hyper IgE syndrome); erythroderma (in Omen syndrome); viral warts or molluscum contagiosum (in autosomal recessive hyper IgE syndrome); chronic mucocutaneous candidiasis (in hyper IgE syndrome, autoimmune polyendocrinopathy candidiasis ectodermal dysplasia syndrome, Th17 cell defects); recurrent nonhealing ulcers (in leucocyte adhesion defect); skin abscesses (in antibody defects, hyper IgE syndrome, and chronic granulomatous disease); petechial or purpuric spots (in Wiskott-Aldrich syndrome).

Qualitative research in medicine - An art to be nurtured

To acquire complete knowledge on a subject both qualitative and quantitative research methods need to be perused by researchers. However, over the period of time qualitative research teaching among medical professionals has reduced. Wisdom amongst doctors seems getting muddled in 'data'. Operational research as well as health systems research have been the basis of 'key' policy changes in situations and programmes including polio immunization to achieve desired objectives. Both qualitative and quantitative methods complement each other and cannot replace one another. We need to protect the 'endangered art' of qualitative research before it becomes extinct from medical schools.

Infant and young child feeding practices amongst children referred to the paediatric outpatient department

BACKGROUND

Worldwide, sub-optimal breastfeeding still accounts for deaths of 1.4 million children aged less than five years. Optimal infant and young child feeding (IYCF) practices have been recognised as the most important intervention for improving child survival and development. Causal association has been found between exclusive breastfeeding with infection-specific infant morbidity and mortality.

METHODS

A cross sectional study was undertaken to assess the IYCF practices among 100 caregivers of children aged less than five years, using a semi-structured questionnaire, attending the Paediatric OPD.

RESULTS

Children from higher income groups were not given colostrum at birth. 57% mothers started breastfeeding within an hour and 88% of the mothers admitted to have given prelacteal feed. Healthy complementary food was found to be given by most of the mothers. Prevalence of infections was found to be higher (p < 0.05) in children whose birth weight < 2.5 kg and in bottle fed children.

CONCLUSION

Traditional beliefs and practices, besides lack of knowledge regarding current feeding recommendations, were found to have played an important role in the feeding practices. Creating an enabling environment for comprehensive nutrition education of mothers by health care providers is required.

Emerging organisms in a tertiary healthcare set up

BACKGROUND

One-tenth of all infectious diseases are attributable to emerging organisms. As emerging organisms sporadically affect a relatively small percentage of population they are not studied at large. This study was aimed at studying the characteristics of emerging organisms encountered from various clinical samples in an apex tertiary care multispeciality teaching and research hospital.

METHODS

16,918 positive isolates obtained from 66,323 culture samples processed in the clinical microbiology lab of an apex multispeciality hospital during 2011-2012 were included after a pilot study. Both manual and automated systems were used for identification and antimicrobial susceptibility. The frequency of isolation, sources, referring centers, resistance and susceptibility profiles, phenotypic characteristics and number of reports in PubMed were studied.

RESULTS

Out of 16,918 isolates, 13,498 (79.78%) were Gram negative bacteria, 3254 (19.23%) were Gram positive bacteria and 166 (0.98%) were yeasts. A total of 483 (2.85%, 95% CI 2.6%-3.1%) emerging organisms including 116 (0.69%, 95% CI 0.57%-0.81%) emerging species were identified comprising 54 genera.

CONCLUSION

Emerging organisms are likely to evade routine identification or be disregarded as non-contributory. Astute efforts directed at identification of emerging isolates, decisions by clinical microbiologists and treating physicians and containment of infection are required.

Health promotion initiatives: An experience of a Well Women's Clinic

BACKGROUND

Army Medical Corps provides comprehensive health care services to troops and their dependents. This approach is in consonance with the concept of Health Promoting Hospitals (HPH) initiative introduced by WHO in 1986. However, the concept is still at an infancy stage in civil health care system in India. This article describes the experiences and advantages of establishing a Well Women's Clinic (WWC) in a station of North India.

METHODS

A system analysis approach was followed for analyzing input, process and output of the WWC during 2007-2009. Inputs included manpower and material i.e public health expert, non medical attendant and a nursing officer charts, poster, models, Television with Compact Disc (CD) player and CDs etc. Health promotion activities were conducted in the form of lectures, demonstrations, workshops, training, screening of movies, quiz, essay writing and declamation contests etc.

RESULTS

Overall 385 lectures, 12 competitions, 07 training capsules were conducted. Coverage of target population was 92%. First aid training workshop trained 300 women. Six percent of the counseled women opted for tubectomy. Twelve new cases of diabetes and four new cases of hypertension were detected through screening. Seventy-two women were referred for dental treatment after a dental screening camp.

CONCLUSION

Establishment of WWC using HPH approach was quite cost effective.

Biomedical waste disposal: A systems analysis

BACKGROUND

In view of the contemporary relevance of BMW Management, a system analysis of BMW management was conducted to ascertain the views of Service hospitals/HCE's on the current system in BMW management in-vogue; to know the composition and quantity of waste generated; to get information on equipment held & equipment required and to explore the possibility of outsourcing, its relevance and feasibility.

METHODS

A qualitative study in which various stake holders in BMW management were studied using both primary (Observation, In-depth Interview of Key Personnel, Group Discussions: and user perspective survey) and secondary data.

RESULTS

All the stake holders were of the opinion that where ever possible outsourcing should be explored as a viable method of BMW disposal. Waste generated in Colour code Yellow (Cat 1,2,3,5,6) ranged from 64.25 to 27.345 g/day/bed; in Colour code Red (Cat 7) from 19.37 to 10.97 g/day/bed and in Colour code Blue (Cat 4) from 3.295 to 3.82 g/day/bed in type 1 hospitals to type 5 hospitals respectively.

CONCLUSION

Outsourcing should be explored as a viable method of BMW disposal, were there are government approved local agencies. Facilities authorized by the Prescribed Authority should be continued and maintained where outsourcing is not feasible.

Polio Eradication in India: Myth or Reality

BACKGROUND

Poliomyelitis has been eradicated from large parts of the world. In South East Asian Region, India and Pakistan remain the only countries where active transmission of the disease persists. A decade-long initiative to eradicate the disease is in progress in India. Initial results were encouraging, with the number of fresh polio decreasing till 2001. The year 2002, however, witnessed a setback, with significant rise in cases of poliomyelitis.

METHODS AND RESULTS

The eradication measures have been reviewed. The corrective measures appear to be succeeding. Various facets of eradication and their impact are evaluated.

CONCLUSION

Poliomyelitis is controlled but the ultimate target of eradication may still be elusive, keeping in mind operational lacunae and vaccine virus characteristics.

The Highest Battlefield of the World : Medical Problems and Solutions

The Indian Armed Forces Medical Services has been engaged in providing medical to the soldiers serving on Siachen Glacier for the last 25 years. This paper attempts to highlight the medical problems faced by troops on the world's highest battlefield as perceived by a medical officer located on the forward most medical echelon on Siachen Glacier. The medical problems on the glacier include high altitude pulmonary oedema, acute mountain sickness, frost bite chilblains, hypothermia, snow blindness, injury non enemy action due to avalanches, crevasses and fires, carbon monoxide poisoning and problems in disposal of nightsoil. A large number of problems are taken care of by following a well documented acclimatisation drill. However under such conditions providing medical support is a difficult task and requires innovations and improvisations entailing a high degree of mental mobility on the part of medical commanders and the Regimental Medical Officers located on the forward posts.

Injection induced nerve injury : an iatrogenic tragedy

11 patients with injection induced nerve injury were evaluated. There were 9 adults and 2 children, 8 had radial nerve injury and 3 sciatic nerve injury. 6 had evidence of severe involvement with active denervation. Nature of the drug was not known in 81%, thus faulty site of injection was the most important factor responsible. The need to discourage indiscriminate use of intramuscular injections and choice of a proper site of selection is stressed.

Herpes Gestationis (pemphigoid Gestationis)

Three patients of herpes gestationis, a rare dermatosis of pregnancy, are being described along with a short review of literaure on the recent immunological backdrop. The characteristic periumbilical cutaneous lesions with classical buflae en cocade appeared during the third trimester of pregnancy and were controlled with corticosteroids. Classical histopathological basal cell necrosis in all the three patients and C3 deposition on dermo-epidermal interface in two patients were demonstrated. Post partum exacerbation was noted in all the three patients. Re occurred after 13 weeks in one patient, the rest did not report for follow up.

Investigation of Erythrina spp. VII. Chemical constituents of Erythrina variegata var. orientalis bark

The petroleum ether extractive of the bark of Erythrina variegata var. orientalis was fractionated and shown to be composed of wax alcohols and wax acids, alkyl ferulates, alkyl phenolates, stigmasterol, sitosterol, campesterol and possibly citrostadienol/24-methylenelophenol. The ethanol extractive yielded chloroform-soluble and water-soluble bases, identified as erysovine and stachydrine, respectively.