A case report of visceral leishmaniasis and malaria co-infection with pancytopenia and splenomegaly - a diagnostic challenge

Background

Leishmaniasis and malaria are tropical diseases with more than half of the world population at risk of infection resulting in significant morbidity and mortality. Co-infection of Leishmaniasis and malaria pose a great challenge in the diagnosis as well as overall management.

Case presentation

In this case report, we present a rare case of a 5 years old child hailing from non-endemic region of Nepal with history of fever for a period of 3 months who was diagnosed as co-infection of malaria due to Plasmodium vivax and visceral Leishmaniasis with pancytopenia that subsequently improved after a course of treatment.

Conclusions

A high index of suspicion for a possibility of co-infection with Leishmaniasis and malaria should be borne in mind when an individual hailing from or having history of travel to endemic countries presents with prolonged fever.

Hereditary Spherocytosis with Splenomegaly and Cholelithiasis in a Young Male of Western Region of Nepal - A Case Report

Hereditary spherocytosis is an autosomal dominant congenital hemolytic anemia due to defect in RBC membrane protein that commonly presents with intermittent jaundice, anemia, abdominal pain, splenomegaly and sometimes cholelithiasis. Due to the membrane defect, there is increased fragility, hemolytic anemia, marked splenomegaly and hyperbilirubinemia. This is a report of an 11 years old male diagnosed case of hereditary spherocytosis who presented with jaundice, splenomegaly and cholelithiasis. He underwent elective open splenectomy and cholecystectomy after prophylactic immunization for capsulated organisms and was advised lifelong oral penicillin prophylaxis post-splenectomy.

Hyperkalaemia in the age of aldosterone antagonism

Hyperkalaemia is well recognized as a medical emergency. However, with the publication of trials showing benefit with renin-aldosterone axis suppression in heart failure, the epidemiology of patients presenting with hyperkalaemia has changed. The reported incidence of rate of serious hyperkalaemia (>6.0 mEq/l of potassium) ranges from 6 to 12% in patients on spironolactone with congestive cardiac failure (CCF). A rational choice of therapy based on present evidence is different from the traditionally used algorithm, given our understanding of the physiology relevant to this patient group. This article discusses the changing face of hyperkalaemia and the present evidence and discusses options in treatment of hyperkalaemia.

Tired heart and mute brain: handle with care

Managing a case of stroke is complex. Presence of variable sized brain infarct and heart failure is even more complex to manage. On top of this, presence of clot in the heart adds to confusion in medical management of stroke patients because of limited scientific evidences. With increasing number of stroke patients and improving diagnostic facility, it is interesting to find thrombus in ventricles of few of these patient, which otherwise were uncommon previously in our set up. We present a 64-year-old man, a case of ischemic stroke caused by left ventricular thrombus secondary to dilated cardiomyopathy and highlight the present recommendation to manage the condition. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6714 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 68-70  

Belatacept as maintenance immunosuppression for postrenal transplant de novo drug-induced thrombotic microangiopathy

De novo posttransplant thrombotic microangiopathy (TMA) is a complication of solid organ transplantation, which remains difficult to treat. In many cases, immunosuppressants and particularly calcineurin inhibitors, trigger TMA. Although withdrawing the offending drug may lead to resolution of TMA, graft and patient outcomes are poor. Specific treatments, including plasma exchange, have not gained widespread acceptance in those with fulminant disease and new approaches to the condition are urgently needed. We report a case of posttransplant de novo TMA presenting serially in association with ciclosporin, tacrolimus and sirolimus in a young recipient of a living donor kidney transplant. We describe a patient treated with belatacept, a novel CTLA4 Ig fusion protein, as ongoing maintenance immunosuppression to allow avoidance of conventional agents once associated with TMA. We report excellent early graft outcome, with no adverse events using this strategy. We suggest that belatacept may have a role in this traditionally difficult-to-treat group of patients.

HAEMODIALYSIS IN B. P. KOIRALA INSTITUTE OF HEALTH SCIENCES, DHARAN - AN INITIAL EXPERIENCE

Dialysis supports life, in spite of complete cessation of renal functions. Haemodialysis(HD) service became available in B. P. Koirala Institute of Health Sciences, Dharansince September 1999. Six hundred and sixty one sessions of HD in 50 patients werecarried out in one year. End stage renal disease (ESRD), acute renal failure (ARF),acute on chronic renal failure constituted 54%, 26% and 20% of the patientsrespectively. Majority of the patients (72%) were between 15 to 50 years of age. Chronicglomerulonephritis, chronic interstitial nephritis, and diabetes nephropathy were themost common causes of ESRD. Recovery following HD was 70% in ARF,whileallpatients of acute on chronic renal failure improved following few sessions of HD.Drop out rate on maintained haemodialysis (MHD) was 52%. The increasing demandof dialysis service in this region is difficult to fulfill due to restricted facilities fordialysis, lack of renal transplantation in Nepal, and economic constraint in the part ofpatients. Primary and secondary prevention of renal diseases by community education,awareness and participation needs emphasis. Key Words: Haemodialysis, End stage renal disease, Acute renal failure,Acute on chronic renal failure.