Metabolic and other morbid complications in congenital generalized lipodystrophy type 4

Morbidity and mortality rates in patients with autosomal recessive, congenital generalized lipodystrophy type 4 (CGL4), an ultra-rare disorder, remain unclear. We report on 30 females and 16 males from 10 countries with biallelic null variants in CAVIN1 gene (mean age, 12 years; range, 2 months to 41 years). Hypertriglyceridemia was seen in 79% (34/43), hepatic steatosis in 82% (27/33) but diabetes mellitus in only 21% (8/44). Myopathy with elevated serum creatine kinase levels (346-3325 IU/L) affected all of them (38/38). 39% had scoliosis (10/26) and 57% had atlantoaxial instability (8/14). Cardiac arrhythmias were detected in 57% (20/35) and 46% had ventricular tachycardia (16/35). Congenital pyloric stenosis was diagnosed in 39% (18/46), 9 had esophageal dysmotility and 19 had intestinal dysmotility. Four patients suffered from intestinal perforations. Seven patients died at mean age of 17 years (range: 2 months to 39 years). The cause of death in four patients was cardiac arrhythmia and sudden death, while others died of prematurity, gastrointestinal perforation, and infected foot ulcers leading to sepsis. Our study highlights high prevalence of myopathy, metabolic abnormalities, cardiac, and gastrointestinal problems in patients with CGL4. CGL4 patients are at high risk of early death mainly caused by cardiac arrhythmias.

Integrated Care for Type 1 Diabetes: The West Bengal Model

Introduction

A structured dedicated health programme for Type 1 diabetes mellitus (T1DM) has been initiated in the state of West Bengal, India.

Aim

The aim is to provide comprehensive healthcare to all children, adolescents and young adults living with T1DM, along with the provision of free supply of insulin, glucose measuring devices, blood glucose test strips, and other logistics. The strategic framework for programme implementation is to utilise the infrastructure and manpower of the already existing non-communicable disease (NCD) clinic under National Health Mission.

Methodology

Establishing dedicated T1DM clinics in each district hospital by utilising existing healthcare delivery systems, intensive training and hand-holding of named human resources; providing comprehensive healthcare service and structured diabetes education to all T1DM patients; and building an electronic registry of patients are important components of the programme. T1DM clinics run once a week on the same day throughout the state. All T1DM patients are treated with the correct dose of insulin, both human regular insulin and glargine insulin. Patients are routinely monitored monthly to ensure good glycaemic control and prevent complications of the disease. Routine anthropometric examination and required laboratory investigations are conducted in the set-up of the already existing NCD clinic. Ongoing monitoring and evaluation of the T1DM programme are being conducted in terms of glycated haemoglobin (HbA1c) values, growth and development, complication rates, psychological well-being, quality of life, and direct and indirect expenditure incurred by families. Through this programme, any bottlenecks or gaps in service delivery will be identified and corrective measures will be adopted to ensure better health outcomes for those living with T1DM.

Investigating a microbial approach to water conservation: Effects of Bacillus subtilis and Surfactin on evaporation dynamics in loam and sandy loam soils

Semi-arid regions faced with increasingly scarce freshwater resources must manage competing demands in the food-energy-water nexus. A possible solution modifies soil hydrologic properties using biosurfactants to reduce evaporation and improve water retention. In this study, two different soil textures representative of agricultural soils in Kansas were treated with a direct application of the biosurfactant, Surfactin, and an indirect application via inoculation of Bacillus subtilis. Evaporation rates of the wetted soils were measured when exposed to artificial sunlight (1000 W/m2) and compared to non-treated control soils. Experimental results indicate that both treatments alter soil moisture dynamics by increasing evaporation rates by when soil moisture is plentiful (i.e., constant rate period) and decreasing evaporation rates by when moisture is scarce (i.e., slower rate period). Furthermore, both treatments significantly reduced the soil moisture content at which the soil transitioned from constant rate to slower rate evaporation. Out of the two treatments, inoculation with B. subtilis generally produced greater changes in evaporation dynamics; for example, the treatment with B. subtilis in sandy loam soils increased constant rate periods of evaporation by 43% and decreased slower rate evaporation by 49%. In comparing the two soil textures, the sandy loam soil exhibited a larger treatment effect than the loam soil. To evaluate the potential significance of the treatment effects, a System Dynamics Model operationalized the evaporation rate results and simulated soil moisture dynamics under typical daily precipitation conditions. The results from this model indicate both treatment methods significantly altered soil moisture dynamics in the sandy loam soils and increased the probability of the soil exhibiting constant rate evaporation relative to the control soils. Overall, these findings suggest that the decrease in soil moisture threshold observed in the experimental setting could increase soil moisture availability by prolonging the constant rate stage of evaporation. As inoculation with B. subtilis in the sandy loam soil had the most pronounced effects in both the experimental and simulated contexts, future work should focus on testing this treatment in field trials with similar soil textures.

A Cross-sectional Study of Stretched Penile Length in Boys from West Bengal, India

INTRODUCTION

Short penile length is a commonly encountered problem in clinical practice. Detection of abnormal stretched penile length (SPL) warrants appropriate endocrine evaluation. Ethnicity-specific SPL data are required to detect these abnormalities. There is a dearth of such data in India. This study aims to establish normative values of SPL in boys from West Bengal.

MATERIALS AND METHODS

This is a cross-sectional study. SPL, testicular volume (TV), height/length, and weight were measured in 460 boys aged 1 to 13 years from the schools located at urban, suburban, and rural areas in the state of West Bengal, India. Similar data were collected from 36 healthy neonates within 1-3 days of full-term delivery at IPGME and R and SSKM Hospital, Kolkata, West Bengal, India.

RESULTS

The 5^th percentile, median, and 95^th percentile of SPL were 1.7, 2.0, and 2.7 cm for neonates; 3.5, 4.4, and 6.4 cm for the children aged 1 Y-2 Y 11 M; 4.0, 5.5, and 7.0 cm for the age group 3 Y-4 Y 11 M; 4.2, 6.0, and 7.2 cm for the age group 5 Y-6 Y 11 M; 4.3, 6.0, and 7.6 cm for the age group 7 Y-8 Y 11 M; 4.4, 6.5, and 9.0 cm for the age group 9 Y-10 Y 11 M; and 4.8, 7.0, and 11.0 cm for the age group 11 Y-12 Y 11 M, respectively. SPL showed significant positive correlation with TV [r = 0.365, P < 0.0005] and height of the children [r = 0.516, P < 0.0005], but not with BMI.

CONCLUSION

Our study provides normative data of SPL in neonate and children aged 1 to 13 years from the eastern part of India. SPL value correlated positively with TV and height of children.

Reversible Secondary Osteolysis in Diabetic Foot Infection

Osteolysis, caused by active resorption of bone matrix by osteoclasts, can be primary or can develop secondary to a variety of disease processes. An elevated level of inflammatory cytokines in the local milieu and increased blood flow secondary to infection or autonomic neuropathy stimulate the osteoclasts and cause bone loss in the diabetic foot. Charcot's neuroarthropathy and osteomyelitis are well-known foot complications of diabetes, and secondary osteolysis has largely been underappreciated and, hence, underreported. Plain radiographs, an initial component in the evaluation of the diabetic foot, may not successfully differentiate secondary osteolysis from osteomyelitis. We describe a patient with phalangeal osteolysis secondary to soft-tissue infection in whom a correct and timely diagnosis helped avoid unnecessary surgical interventions.

Pituitary gigantism: a case report

OBJECTIVE

To present a rare case of gigantism.

CASE REPORT

A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years. She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory. Blood pressure was normal. Height 221 cm, weight 138 kg, body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal. Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.

The "Double A" phenotype: Portending Allgrove's syndrome and averting adrenal crisis

INTRODUCTION

Allgrove's syndrome is a rare autosomal-recessive disorder with only about 70 cases reported thus far and is characterized by alacrima, achalasia, and ACTH insensitivity among other clinical features. However, it has a widely variable clinical presentation, which may result in such cases remaining undiagnosed.

OBJECTIVE

To report a patient with impending Allgrove's syndrome and to highlight the importance of clinical suspicion in diagnosing the same.

MATERIALS AND METHODS

A 2.5-year-old girl was diagnosed with impending Allgrove's syndrome on the basis of clinical presentation, barium swallow study, Schirmer's test, and hormonal evaluation.

RESULTS

A 2.5-year-old girl, born of non-consanguineous marriage, presented with failure to thrive and developmental delay with occasional vomiting on taking solid or semi-solid food for past 6 months. Examination revealed stunted weight (SDS of -4.4) and height (SDS of -4.76), and barium swallow showed presence of achalasia. On direct questioning, her mother mentioned presence of decreased tears on crying since birth, and Schirmer's test confirmed the presence of dry eyes. Baseline ACTH was slightly elevated with normal basal and post-ACTH stimulation serum cortisol. Based on these findings, impending Allgrove's syndrome was diagnosed with a plan for follow-up study of adrenal function.

CONCLUSIONS

Allgrove's syndrome may be an under diagnosed disorder as aclarima is often overlooked. However, a high index of clinical suspicion may help in avoiding adrenal crisis by diagnosing the condition early.

Utility of abdominal ultrasonography in HIV patients

INTRODUCTION

Various diseases associated with human immunodeficiency virus (HIV) infection are often difficult to diagnose. A poor immune response, atypical presentations and opportunistic pathologies all contribute to this difficulty. We tried to evaluate the utility of routine abdominal ultrasonography (US) in new and follow-up HIV cases, and compared the results among those with a clinical need for US and those where US was performed as a routine screening.

METHODS

150 consecutive seropositive patients were subdivided into four groups depending on the necessity of abdominal US on the initial workup, i.e. Group A (38 patients) or B (112 patients), and whether they were newly-diagnosed HIV patients or follow-up patients, i.e. Group X (62 patients) or Y (88 patients), giving us subgroups, AX (22 patients), AY (16 patients), BX (40 patients) and BY (72 patients).

RESULTS

The prevalence of significant US findings was higher in those with CD4 less than 200 cells/ml (77.8 percent) compared to those with CD4 200-500 cells/ml and CD4 more than 500 cells/ml (65.5 percent and 37 percent, respectively). 24 out of 38 patients with clinical indications and 71 out of 112 patients without any obvious clinical need for US, had positive findings on US, the majority of which had a major therapeutic impact.

CONCLUSION

We conclude that abdominal US is a simple and cost-effective tool in resource-poor countries like India, where HIV care is becoming more and more important.

Scleredema of Buschke: a rare post-streptococcal complication

A 19-year male presented with acute onset, gradually progressive symmetric indurations involving the skin over the face, neck, shoulders and upper part of chest following an upper respiratory tract infection. Detailed history and examination did not reveal evidence of Raynauds' phenomenon, nail changes, digital ulcers, pigmentation or any systemic involvement. Autoantibodies for systemic sclerosis were absent. Histopathology of skin biopsy documented scleredema. Antistreptolysin O (ASO) titer was elevated. We diagnosed a case of Scleredema adultorum of Buschke following a streptococcal throat infection. We report this case to highlight the importance of clinically differentiating this relatively benign, self-limiting disorder from systemic sclerosis.

A rare variant of Ellis van Creveld syndrome

A nine-year-old boy presented with progressively-increasing exertional dyspnoea for the last three months. The only significant finding in the general survey was polydactyly. His vital signs were normal. He had a prominent apical diastolic thrill, a prominent S1 with a low-pitched grade 4/6 mid diastolic rumbling murmur over the apex. The S2 was widely split, fixed and the second component was louder than the first one. There was a grade 3/6 ejection systolic murmur over the left second intercostal space. Electrocardiography showed features of left axis deviation, bi-atrial enlargement and right ventricular hypertrophy. Transthoracic echocardiography identified a thin undulating intra-atrial membrane on the left side along with an ostium-primum defect. In this patient, the diagnosis of a variant of Ellis van Creveld syndrome was made.

Mitochondrial myopathy associated with myasthenia gravis in a young man

An 18-year-old man presented with progressive weakness of proximal muscles with prominent diurnal variation for 3 months. He had bilateral ptosis since his childhood without diurnal variation or double vision. Neurological examination showed involvement of levator palpebrae superioris and lateral rectus muscles bilaterally. The plasma glucose after 75 gm glucose load was 302 mg/dL. The electrophysiological study revealed myopathic pattern and a decremental response in repetitive nerve stimulation. The plasma lactate was elevated and the muscle biopsy showed numerous ragged-red fibers. Serum acetylcholine receptor antibody assay was positive. We diagnosed myasthenia gravis with mitochondrial myopathy.

Doubtful descent, dilemma and diagnosis: a case of Kallmann syndrome

A 16-year-old boy with a diagnosis of bilateral cryptorchidism was referred for preoperative evaluation. He had diminished hearing and difficulty in vision since birth, with inattentiveness, poor school performance and delayed milestones. He was previously operated on for cleft lip. General survey revealed bilateral short fourth metacarpals and an operative scar mark over the left nostril and upper lip. He had a micropenis, small soft testes with anosmia, and sensory-motor deafness. The hormonal assay was consistent with hypogonadotrophic hypogonadism. Magnetic resonance imaging of the brain and computed tomography cisternography revealed almost hypoplastic olfactory bulb with an ill-defined olfactory tract and sulci, supporting the clinical diagnosis of Kallmann syndrome.

Multiorgan involvement due to cytomegalovirus infection in AIDS

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

Observations of hepatic encephalopathy profile in a tertiary care centre

A study was conducted among 67 patients presenting with hepatic encephalopathy to establish the aetiological diagnosis and record the incidence of acute and chronic liver diseases. They all had undergone thorough clinical and laboratory evaluation. The factor precipitating encephalopathy was also identified. Among 67 patients 19 (28.4%) had acute liver disease and 48 (71.6%) had chronic liver disease. Majority of patients had grade 2 encephalopathy at presentation. Among the acute cases most common aetiology was acute viral hepatitis due to hepatitis B and E viruses whereas alcoholic liver disease was the most frequent cause of chronic liver disease. The most common precipitating factor was gastro-intestinal haemorrhage.

Glycaemic consequences of HIV and highly active antiretroviral therapy: a pilot study and review of literature

The metabolic consequences of HIV and AIDS are accentuated in the setting of highly active antiretroviral therapy. Peripheral lipodystrophy, central adiposity, hyperlipidaemia, insulin resistance and diabetes mellitus are frequent associations of protease inhibitor containing highly active antiretroviral therapy regimens. Ninety patients aged 25-50 years (males 52, females 38), seropositive for HIV 1 and 2 or both were selected to see the glycaemic profiles in asymptomatic early HIV disease with CD4 counts > 100/microl and to compare this with the glycaemic profile of (a) advanced HIV disease (CD4 counts < 200/microl), not on highly active antiretroviral therapy and (b) advanced HIV disease (CD4 counts < 200/microl), on uninterrupted non-protease inhibitor highly active antiretroviral therapy > 6 months. All the patients were grouped into 3: (1) Group A: CD4 counts > 500/microl (n=37), highly active antiretroviral therapy naive, (2) group B: CD4 counts < 200/microl (n=21), not on highly active antiretroviral therapy, and (3) group C: CD4 counts < 200/microl, receiving uninterrupted non-protease inhibitor based highly active antiretroviral therapy for > 6 months (n=32). The fasting blood glucose, glycosylated Hb (HbA1c) levels, were measured in all the patients in 3 groups and significance of difference between means was calculated among various groups. Body weight and waist-hip ratio were also measured. The results were analysed and compared with other studies.