Acute Presentation of Primary CNS Lymphoma Mimicking Toxoplasma in HIV Infection

Primary CNS lymphoma (PCNSL) accounts for up to 15% of non-Hodgkin lymphomas in HIV patients and is the second most common cause of space-occupying brain lesions in HIV patients after CNS toxoplasmosis. Differentiation of PCNL and CNS toxoplasmosis is crucial as PCNL carries a poor prognosis with survival time of 2-4 months without treatment but can be improved with prompt initiation of chemotherapy. These two entities often present clinically in a similar manner, and conventional imaging can also be a diagnostic challenge due to overlapping imaging characteristics. Thus, definitive diagnosis of PCNSL relies on histopathologic confirmation. Here, we present a case of intracranial lesion that presented acutely in the context of headache and left sided body weakness and was found to have PCNSL.

Coronary artery bypass grafting for triple vessel disease in cardiac amyloidosis

Cardiac amyloidosis is a rare condition with an estimated incidence of 18-55 per 100 000 person-years. It is associated with either immunoglobulin light chain (AL) or transthyretin amyloid (ATTR), both of which result in a restrictive cardiomyopathy complicated initially by diastolic dysfunction and subsequently followed by biventricular systolic heart failure. Untreated cardiac amyloidosis carries an extremely poor prognosis with an estimated median survival time of less than 1 year in AL and 4 years in ATTR amyloidosis. This is the sixth described report of coronary artery bypass grafting in patients with underlying cardiac amyloidosis.

Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis

Drug-induced vasculitis can rarely cause inflammation and necrosis of blood vessel walls of both kidney and lung tissue. Diagnosis is challenging because of the lack of difference between systemic and drug-induced vasculitis in clinical presentation, immunological workup and pathological findings. Tissue biopsy guides diagnosis and treatment. Pathological findings must be correlated with clinical information to arrive at a presumed diagnosis of drug-induced vasculitis. We present a patient with hydralazine-induced antineutrophil cytoplasmic antibodies-positive vasculitis with a pulmonary-renal syndrome manifesting as pauci-immune glomerulonephritis and alveolar haemorrhage.

Hepatic segmental arterial mediolysis: A case report and brief literature review

Key Clinical message

When evaluating patients with abdominal pain, it is important to consider SAM in the differential diagnosis, along with vasculitis, fibromuscular dysplasia (FMD), atherosclerosis, mycotic aneurysms, and cystic medial degeneration.

Abstract

Segmental arterial mediolysis (SAM) is a rare arteriopathy which is an under-recognized and commonly missed diagnosis of abdominal pain. We report a case of a 58-year-old female who presented with abdominal pain and was misdiagnosed with a urinary tract infection. The diagnosis was made with CTA and managed with embolization. Despite appropriate intervention and close hospital monitoring, further complications were inevitable. We conclude that though literature has shown better prognosis and even complete resolution after medical and/or surgical intervention, close follow up and monitoring is needed to avoid unexpected complications.

Dry Beriberi Post Roux-en-Y Gastric Bypass Surgery

Bariatric surgery is an effective strategy for achieving substantial weight loss, prolonging survival, and improving the comorbidities associated with obesity. Nutritional deficiency is a commonly recognized post-procedural complication. Here, we present a case of a patient with paresthesia, lower extremity weakness, and altered mental status one year following Roux-en-Y gastric bypass, who was found to have multiple vitamin and micronutrient deficiencies and was diagnosed with beriberi in the setting of profound thiamine deficiency.

Unraveling the Puzzle: A Case Report Questioning the Causal Relationship Between Subarachnoid Hemorrhage and Microscopic Polyangiitis

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are small-to-medium-vessel vasculitis, which includes granulomatosis with polyangiitis, microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis. MPA predominantly affects the kidneys and lungs. Subarachnoid hemorrhage (SAH), a life-threatening condition, rarely occurs with AAV. In this case, we present a 67-year-old female who presented with a sudden-onset headache after a recent diagnosis of ANCA-associated renal vasculitis. Kidney biopsy revealed pauci-immune glomerulonephritis, and serum was positive for ANCA along with myeloperoxidase antibody. A computed tomography scan of the head revealed both SAH and intraparenchymal hemorrhage. The patient was managed medically for SAH and intraparenchymal hemorrhage. ANCA vasculitis was treated with steroids and rituximab, and the patient showed improvement.

Pulmonary Artery Aneurysm Associated With Aspergilloma in a Patient Diagnosed With Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is an autoimmune, necrotizing granulomatous disease that affects small- and medium-sized blood vessels. Aspergilloma is a fungal mass of Aspergillus and usually found in the preexisting cavity in lung parenchyma. Surgical resection is the mainstay of treatment of aspergilloma. In this article, we present a case of a 70-year-old male with GPA and aspergilloma who presented with massive, life-threatening hemoptysis. Further workup with a chest computed tomography (CT) pulmonary angiogram demonstrated a pulmonary artery pseudoaneurysm along the wall of the lung cavity which was emergently managed with embolization and required monitoring in the medical intensive care unit. This case report alerts clinicians to maintain a high level of suspicion for an aneurysm if the degree of hemoptysis is higher than expected.

Antisynthetase Syndrome With Paraneoplastic Antibodies

Antisynthetase syndrome (ASyS) is an uncommon systemic autoimmune disorder characterized by the presence of autoantibodies targeting aminoacyl-transfer RNA (tRNA) synthetase. The syndrome displays a diverse range of clinical manifestations affecting multiple organs, thereby posing a diagnostic challenge. In this report, we present an unusual case of a patient diagnosed with ASyS, displaying positive anti-PL-12 antibodies along with paraneoplastic antibodies. To the best of our knowledge, this is the first documented case in the existing literature describing ASyS with the presence of anti-PL-12 antibodies and concomitant paraneoplastic antibodies in the context of ductal carcinoma in situ.

Overlapping Tubulointerstitial Lupus Nephritis and Immunoglobulin G4-Related Disease: A Case Report

Immunoglobulin G4-related disease (IgG4-RD) in conjunction with systemic lupus erythematosus (SLE) is a rare occurrence. In this case report, we present the case of a 50-year-old female who was diagnosed with SLE based on clinical and laboratory criteria. The patient exhibited pericardial effusion necessitating pericardiocentesis, pleural effusion requiring thoracentesis, and impaired renal function necessitating dialysis. Renal biopsy revealed findings consistent with tubulointerstitial lupus nephritis and IgG4-related disease. Additionally, elevated levels of serum IgG4 were detected. The patient received intravenous pulse dose steroids and oral steroids, which were tapered gradually, followed by daily hydroxychloroquine treatment and two doses of rituximab every two weeks. Consequently, the patient experienced an improvement in renal function and no longer needed dialysis. To our knowledge, only a few reports of this overlap exist. This late diagnosis of SLE could be explained by the fact that IgG4 is associated with milder renal disease in lupus patients, due to its inability to activate the classical complement pathway. IgG4-RD/SLE overlap patients usually respond well to a combination of steroids and other immunosuppressants used to treat SLE. However, our experience with treating this disease overlap remains limited due to its extreme rarity.

Peritoneal Amyloid as a Presenting Manifestation of AL Amyloid

Amyloid is a systemic disease characterized by extracellular deposition of misfolded protein. Gastrointestinal and peritoneal deposition of light chain (AL) amyloid is an under-recognized manifestation of this systemic disease, usually as a late sequela. Here we present a case of recently diagnosed AL peritoneal amyloid that presented in the context of recurrent, acute onset abdominal discomfort and was found to have bowel obstruction complicated by perforation in the setting of AL-mediated gastrointestinal tract infiltration and dysmotility.

Superior Mesenteric Artery Thrombosis and Intestinal Ischemia as a Consequence of COVID-19 Infection

COVID-19-associated arterial and venous thrombotic events are multifactorial in origin, resulting in significant morbidity and mortality. Intestinal ischemia due to thrombus is a rare manifestation of COVID infection. Here, we report the case of a patient who presented with fever, malaise, and diarrhea, and was found to be COVID-19 positive; his clinical course was further complicated by devastating thrombosis of the superior mesentery artery (SMA) associated with COVID-19 infection.

Maternal and Fetal Outcomes in Active versus Expectant Management of prelabor rupture of membrane

Aim: To assess the effects of planned early birth (active treatment within 24hrs) compared to expectant management (without active treatment within 24hrs) for women at term with Prelabor Rupture of Membrane (PROM) on maternal and fetal outcomes. Methods: This is an observational comparative study carried out in all the pregnant women who present in maternity ward of Shree Birendra Hospital with PROM at 37-41 weeks of gestation with vertex presentation during the study period between 13 April 2020 to 13 April 2021.They were randomly placed into (A) active treatment group and (B) expectant treatment group. Group (A) was induced with 25mcg of PGE1 (Misoprostol) depending on cervical score, whereas group (B) was expectantly managed for 24 hrs. PROM to delivery interval, maternal and fetal outcomes were then evaluated in both the groups. Results: 79.5% of group A and 71.8% in group B delivered through vaginal route. 20.5% patients in group A and 28.2% patients in group B underwent Cesarean section. The average PROM to delivery interval was 15.6 hours in group A, as compared to 16.8 hours in group B. Only 2 babies in group B had an Apgar score of less than 7 at five minutes. Subsequently, in both the groups, two babies required NICU admission for respiratory distress syndrome with no neonatal mortality in both the groups. Conclusion: Expectant management up to 24 hours can be safely offered to a woman with term PROM.

Prevalence of Anxiety in Pregnancy during COVID 19 pandemic in Shree Birendra Hospital, Chhauni

Aim: To determine the prevalence of anxiety in pregnancy during COVID19 pandemic in Shree Birendra Hospital, Chhauni Method: It is a cross sectional study conducted at Shree Birendra Hospital Chhauni from July to October 2020 following the ethical approval from IRC. All the pregnant women from first to last trimester attending outdoor visit were included; they were asked to fill up Beck Anxiety Index form. The level of anxiety was compared with demographic data like age, race, parity, and period of gestation, education and occupation. Data were analyzed by using SPSS 20 software. Results: A total of 385 presumably uninfected pregnant women were surveyed in 20-40 (28.45±3.95) years age group from 4 to 41 (27.15±9.4) weeks of pregnancy and 55.6% were multipara. Low-grade anxiety was found 99.5% (BAI= 3.06±3.66). Conclusions: Low-grade anxiety was found in almost all pregnant women during covid pandemic and there was no significant difference by demographic variables.

Endometrial Histopathology in Abnormal Uterine Bleeding: A Retrospective Analysis

Introduction: Abnormal uterine bleeding (AUB) is a very common gynaecological condition that affects women of all age groups. Majority of the cases are diagnosed by sampling the endometrium by procedure like dilatation and curettage (D and C). The aim of this study was to analyse the different types of endometrial histopathology of patients with the abnormal uterine bleeding and to find the association between various patterns of abnormal uterine bleeding and histopathological findings. Methods: This was a retrospective study carried out in the Department of Obstetrics and Gynaecology of Shree Birendra Hospital, Chhauni, Kathmandu over a period of two years from August 2018 to August 2020. All cases of AUB who underwent D and C procedure were included in the study. Data was entered in Microsoft excel and managed in SPSS Version 21. Analysis was done in the form of percentage and proportion and represented as tables where necessary. Results: Total 192 patients were analysed. Age group ranged from 21 to 75 years and most common age group presenting with AUB was 41 to 50 years. The most common presenting complaint was menorrhagia 47.9% (92/192) followed by metrorrhagia 19.8% (38/192). Most common endometrial histopathology was proliferative endometrium 33.3% (64/192), followed by secretory endometrium  21.9 % (42/192). Endometrial malignancy was found in 1.5% (3/192) cases. Conclusions: Histopathological examination of the endometrium showed a wide spectrum of pathological changes ranging from normal endometrium to malignancy. This emphasises the importance of endometrial sampling like D and C as an important diagnostic tool in the management of abnormal uterine bleeding.

Surgical Emergencies among Gynecological Surgeries in a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction:

The management of gynecological emergencies is essential for the preservation of the life of affected woman, her sexual functions and fertility particularly in disease conditions that threaten her life. The main objective of the study is to determine the proportion of the surgical emergencies among gynecological surgeries in a tertiary care center.

Methods:

This is a descriptive cross-sectional study conducted in the department of gynecology and obstetrics in Shree Birendra Hospital, Kathmandu, Nepal from April 2013 till March 2017. Ethical approval was taken from the Institutional Review Committee (IRC) in November 2019. This study was conducted among 515 gynecological surgeries by using convenience sampling methods. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Data were analyzed using EXCEL software.

Results:

In our study, the proportion of surgical emergencies among total gynecological surgeries performed in the department of gynecology and obstetrics in Shree Birendra Hospital was 120 (23.30%). The highest number of surgical emergencies was observed in the age group of 20-29 years old, followed by less than 19 years of old age group. Ectopic pregnancy accounting for 85 (70.83%) is found to be the most common surgical emergencies in our study. Out of all surgical emergency cases, most of them underwent salpingectomy 65 (54.16%) followed by salpingectomy with tubal ligation 20 (16.16%).

Conclusions:

Surgical emergencies among gynecological surgeries are found to be in greater proportion in the department of gynecology and obstetrics in Shree Birendra Hospital. Ectopic pregnancy accounted for more than half of the diagnoses in this study.

Efficacy and Safety of Sublingual versus Vaginal Misoprostol for Pre-induction Cervical Ripening among Primigravida

<p><strong>Introduction: </strong>Induction of labor is an intervention intended to artificially initiate uterine contractions resulting in progressive effacement and dilatation of the cervix. This is a common intervention during pregnancy in both industrialized and non-industrialized countries.Misoprostol is the commonly used induction agent. The objective of this study was to compare the efficacy of sublingual route of misoprostol with that of vaginal for pre-induction cervical ripening at term among Primigravida.</p><p><strong>Methods:</strong> This study was a hospital based cross sectional comparative study, conducted at a tertiary center, Kathmandu over a period of 6 months extending from July 2010 to December 2010. Primigravida at 40-42 weeks of gestation who met the inclusion criteria were enrolled in this study and were randomly enrolled for sublingual misoprostol and vaginal misoprostol.</p><p><strong>Results: </strong>More women in the vaginal misoprostol group had Bishop score more than six after 8 hours of insertion of first dose (80%) compared to those who received sublingual misoprostol (48%). The mean induction to   delivery interval was shorter in the vaginal misoprostol group (12.12 hours) compared to (12.96) in sublingual group. Use of oxytocin for augmentation of labour was required more in the sublingual group but the difference was not significant statistically.</p><p><strong>Conclusion: </strong>Both sublingual and vaginal routes of misoprostol administration were equally effective and appeared safe for pre-induction cervical ripening at term. </p>

Efficacy and Safety of Sublingual versus Vaginal Misoprostol for Pre-induction Cervical Ripening among Primigravida

Introduction: Induction of labor is an intervention intended to artificially initiate uterine contractions resulting in progressive effacement and dilatation of the cervix. This is a common intervention during pregnancy in both industrialized and non-industrialized countries.Misoprostol is the commonly used induction agent. The objective of this study was to compare the efficacy of sublingual route of misoprostol with that of vaginal for pre-induction cervical ripening at term among Primigravida.Methods: This study was a hospital based cross sectional comparative study, conducted at a tertiary center, Kathmandu over a period of 6 months extending from July 2010 to December 2010. Primigravida at 40-42 weeks of gestation who met the inclusion criteria were enrolled in this study and were randomly enrolled for sublingual misoprostol and vaginal misoprostol.Results: More women in the vaginal misoprostol group had Bishop score more than six after 8 hours of insertion of first dose (80%) compared to those who received sublingual misoprostol (48%). The mean induction to   delivery interval was shorter in the vaginal misoprostol group (12.12 hours) compared to (12.96) in sublingual group. Use of oxytocin for augmentation of labour was required more in the sublingual group but the difference was not significant statistically.Conclusion: Both sublingual and vaginal routes of misoprostol administration were equally effective and appeared safe for pre-induction cervical ripening at term. 

High risk pregnancy and Fetal outcome at Shree Birendra Hospital

Introduction: High risk pregnancy is a major cause of morbidity and mortality in a developing country. These patients are recognized in the initial prenatal office visit as they have a poor obstetrical history or a well recognized medical complication however; pregnancy becomes high risk because they develop unexpected complications in the course of otherwise normal pregnancies. The objective of this study is to identify various type of high risk pregnancy and fetal outcome. Methods: This was a descriptive study conducted in Shree Birendra military hospital over a period of 9 months. Patients were recognized as high risk during antenatal visit and during admission. They were followed till delivery. The case records of all high risk pregnancy with their fetal outcome were analyzed. Statistical analysis was done using simple percentage. Results: Total deliveries during study period was 626. High risk pregnancy identified were 99 (15.81%). Previous lower segment cesarean section was the most common identified high risk pregnancy 34 (5.43%) followed by young primigravida 3.19%, breech 2.23%. There were total 13 low birth weight baby (13.13%) and 2 stillbirth (2%) as fetal outcome. Conclusion: Identification of high risk pregnancy during antenatal period will reduce adverse perinatal outcome.

Maternal Morbidity in Vaginal Delivery with or without Episiotomy in Nulliparous Women

Introduction: Episiotomy incision is the most common surgical procedure around the globe and in many countries, it became a routine policy. Episiotomy in all women with vaginal delivery has no benefit. Rate of episiotomy varies widely around the globe, while in Nepal all nulliparous and primi-parous hospital deliveries are given routine episiotomy. So, this study aimed to compare the maternal morbidity during first vaginal birth in women with or without episiotomy.Methods: This is a hospital based randomized prospective comparative study conducted in the Obstetrics and Gynaecology department of a teaching hospital. The subjects were divided into episiotomy group and no episiotomy group. Under local anaesthesia mediolateral episiotomy was given in the second stage with crowning of the head in episiotomy group. Nature of morbidity seen were recorded in both the groups immediately after delivery, after 6 hours and after 1 week and compared.Results: In no episiotomy group intact perineum 26.3%, laceration 10.5%, spontaneous perineal tear (first and second degree) 63.1% was observed. Total perineal surgical repair was 81.55%. Intact perineum was high among no episiotomy group. Third degree tear, vulval haematoma, wound gaping, perineal oedema were seen in episiotomy group.Conclusion: Anterior perineal laceration rate was high in no episiotomy group than episiotomy group but overall few morbidities were in no episiotomy group than in episiotomy group. So, episiotomy should not be considered to prevent insignificant anterior perineal lacerations.

Malaria on the Move : Ecological Considerations for the Armed Forces

BACKGROUND

Armed forces personnel deployed in the North Eastern states of India are vulnerable to falciparum malaria. This vulnerability increases during mobilization of troops.

METHODS

Epidemiological case sheet was used for recording individual movement, clinical features and laboratory investigations of each case of malaria. Immunochromotography test (ICT) or Paracheck Pf was used as a rapid test for falciparum malaria at the regimental aid post (RAP). Subsequently, a case control approach was used to ascertain whether the cases of malaria differed significantly from healthy controls in observing antimalaria measures such as the use of mosquito nets, repellants and chemoprophylaxis.

RESULT

Nineteen out of 623 soldiers suffered from falciparum malaria during a short period of ten days during operational mobilization. Use of mosquito nets and repellants was significantly less among the cases as compared to healthy controls. There was no significant difference among the two groups regarding compliance with chemoprophylaxis.

CONCLUSION

A paradigm of "malaria on the move" or "operational malaria" has been proposed.