Detection of Vascular Changes in Systemic Lupus Erythematosus by Carotid Duplex Study in A Tertiary Cardiac Hospital

Systemic lupus erythematosus (SLE) is a common autoimmune connective tissue disorder and mainly affected female patients. This cross sectional study was performed in the department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2008 to June 2012. A total fifty (50) SLE patients were diagnosed on the basis of ACR criteria, having no cardiovascular symptoms. Another 50 age-matched normal individuals were included to compare with SLE group. Congenital vascular disease, ischaemic heart disease, congenital heart disease, rheumatic heart disease, hypothyroidism and any other inflammatory disease along with SLE were excluded from study. All patients were evaluated by Carotid duplex study. Mean age of SLE was 26.70±7.3 and mean age of normal subject was 25.64±8.01. Most of the SLE patients were female (about 92%) and male (about 8%). And about 94% was female in normal group and 6% was male. In Right common carotid arteries (RCCA), mean Intema medial thickness (IMT) was 0.86±0.10 IN SLE group and 0.73±0.06 in normal group. In LCCA, mean IMT was 0.89±0.14 in SLE group and 0.76±0.10 in normal group. IMT in SLE group was increased than control group. There was a significant difference (p=0.001) in both right and left side. The percentage rate of change in PSV and EDV of Carotid arteries of the SLE group was significantly higher than the control group (Both left and right side p=0.001). In RCCA, the PSV was 91.72±19.46 in SLE group and 62.60±6.66 in normal group (p=0.001). And EDV was 27.02±8.23 in SLE group and 16.48±2.32 in normal group (p=0.001). In LCCA, the PSV was 82.06±22.28 in SLE group and 60.36±7.54 in normal group (p=0.001). And EDV was 27.82±6.61 in SLE group and 18.08±2.69 in normal group (p=0.001). In LICA, mean PSV was 83.46±23.54 in SLE group and 60.36±7.54 in normal group (p=0.001). And EDV was 29.36±8.56 in SLE group and 18.08±2.69 in normal group (p=0.001). In RICA, mean PSV was 61.56±7.66 in SLE group and 62.16±5.35 in normal group (p=0.651) which was not significant. And EDV was 26.36±2.26 in SLE group and 19.00±2.17 in normal group (p=0.001). But majority of the vessels showed significant P value which signifies that vascular changes were more evident in SLE group than normal control group. SLE patients with carotid artery blood flow velocity and structural changes in endothelial function changes more evident than control group. Compared with the normal control group, IMT, PSV and EDV were significantly higher in SLE group, the difference was statistically significant (P<0.05). Vascular changes are common in SLE when clinically asymptomatic. Carotid duplex study is a non invasive tool for early detection of vascular changes to prevent stroke in SLE patients.

Typhoid Fever

Typhoid fever is one of the most common febrile illnesses encountered by the physicians in Bangladesh. Diagnosis is not difficult but has lately become a challenge due to changed clinical pattern of the disease, lack of adequate facilities for blood, stool, urine culture, excessive reliance on nonspecific Widal test and non availability of any reliable rapid diagnostic tests. Further, the indiscriminate and injudicious use of antibiotics for treating fever in undiagnosed febrile illnesses early has created problems to the physicians to reach to a diagnosis later on. This has also led to the emergence of high level resistance to many of the commonly used antibiotics in our country. Ciprofloxacin is often used empirically for treating the disease though there is already a high level resistance. In case the organism is in-vitro sensitive to ciprofloxacin but resistant to nalidixic acid, a much higher dose of drug is required to maintain the MIC which is 10 times higher than usual. Third generation cephalosporins (ceftriaxone and cefixime) are still the effective drugs for treating typhoid fever. The drug needs to be used in proper dose and duration to prevent emergence of resistance. Azithromycin though advocated by many as an alternative to ciprofloxacin in resistant cases, has recently lost its credibility due to emergence of resistance. We should not rely on Widal test in diagnosing typhoid fever. In a suspected case, the patient should not be prescribed any antibiotic without sending blood sample for culture sensitivity.