A Case Series of Dengue Myocarditis: A Complication Observed in Dengue Patients

Dengue is a prevalent arthropod-born viral disease with a wide spectrum of clinical presentations ranging from undifferentiated fever to a more severe form of the disease, dengue hemorrhagic fever, and dengue shock syndrome. However, atypical manifestations such as hepatic, neurological, cardiac, and kidney involvement are increasingly being reported, thus the term "expanded dengue syndrome". We report a series of cases with an atypical presentation of dengue fever marked by various cardiac manifestations, including cardiogenic shock secondary to myocardial involvement.

Pancreatic Injury in COVID-19 Patients

BACKGROUND AND AIM

Coronavirus disease 2019 (COVID 2019) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause multisystem dysfunction. We studied pancreatic injury (serum amylase and serum lipase levels) in COVID-19 patients.

METHODS

A retrospective study involving 42 COVID-19 patients (diagnosed by real-time PCR) admitted to a tertiary care hospital was conducted. Serum amylase and serum lipase levels were analysed in relation to severity of COVID-19 and mortality.

RESULTS

Mean age of patients was 50 ± 16 years, with male to female ratio of 3.7:1. Serum amylase was elevated in 14 patients (33%). Serum lipase was elevated in 7 out of 29 patients (24.1%). Mortality was seen in 18 patients (42.8%). Serum amylase or lipase did not correlate with severity of COVID-19 or its mortality. However, both patients who had high lipase (>3times) died.

CONCLUSION

The prevalence of hyperamylasemia in patients of COVID-19 was 33%, while that of elevated lipase was 24.1%. Pancreatic injury failed to show any statistically significant relation to severity or outcome of COVID-19.

COVID-19 and Tuberculosis: A Meeting of Two Pandemics!

Coronavirus disease 2019 (COVID-19), causes serious respiratory illness manifesting as pneumonia, adult respiratory distress syndrome and respiratory failure. Amidst the rising number of cases and deaths, it is imperative to not forget Tuberculosis (TB) which is another pandemic existing since centuries. There could be dire consequences for tuberculosis patients globally especially in low and middle income countries with a high burden of disease and overwhelmed health care systems. Tuberculosis is still the leading infectious killer worldwide, and therefore, it is crucial to reflect on the interaction between the two diseases. Evidence suggests that both COVID-19 and tuberculosis have a synergistic relationship, boosting detrimental effect of each other, disrupting existing health care models, and also worsening the clinical outcomes in terms of morbidity and mortality. This review aims to draw attention towards this pertinent clinical issue, and tries to unravel the intricate relationship between COVID-19 and tuberculosis, as also the role of BCG vaccination to combat the COVID-19 pandemic.

New insights into anaplastic lymphoma kinase-positive nonsmall cell lung cancer

BACKGROUND

A novel fusion gene of echinoderm microtubule-associated protein-like 4 (EML4) and anaplastic lymphoma kinase (ALK) has been identified in a subset of non-small-cell lung cancers (NSCLCs). Patients with the ALK-EML4 fusion gene demonstrate unique clinicopathological and physiological characteristics. Here we present an analysis of clinicopathological profile of patients of metastatic adenocarcinoma harboring the ALK-EML4 fusion gene and their response to targeted therapy in the form of crizotinib.

METHODS

A retrospective analysis of advanced ALK positive NSCLC, who presented at this tertiary care hospital of armed forces from September 2014 to December 2016 was conducted. The primary goal was to evaluate demographic and clinicopathological profile of ALK positive advanced NSCLC. Detection of ALK fusion was done by IHC on formalin fixed paraffin embedded cell blocks. Out of 20 ALK positive patients, ten patients received upfront cytotoxic chemotherapy, and rest received crizotinib. Patients progressing on cytotoxic chemotherapy received crizotinib as subsequent therapy.

RESULTS

Out of 270 patients of NSCLC, fifteen(7.4%) tested positive for ALK-EML4 fusion. Rate of positivity was higher in females(13.7%) than in males (5%). The correlation of the ALK-EML4 fusion gene and clinicopathological characteristics of NSCLC patients demonstrated a significant difference in smoking status, histological types, stage, & metastatic pattern. Median PFS with first line cytotoxic chemotherapy was 5.9 months. Median PFS with upfront crizotinib was not reached, but was significantly superior than cytotoxic chemotherapy.

CONCLUSION

Our analysis indicated that ALK-EML4 positive NSCLC comprised a unique subgroup of adenocarcinomas with distinct clinicopathological characteristics. Incidence of ALK positivity was found to be higher in females and never smokers. These patients have distinct pathological and radiological characteristics. Crizotinib, whether used upfront or as subsequent therapy was found to be superior in PFS (not yet reached at the time of writing this article), and maintaining quality of life as compared to cytotoxic chemotherapy.

Sofosbuvir plus ribavirin in treatment-naïve patients with chronic hepatitis C virus genotype 1 or 3 infection in India

Until 2014, pegylated interferon plus ribavirin was the recommended standard of care for the treatment of chronic hepatitis C virus (HCV) infection in India. This open-label phase 3b study, conducted across 14 sites in India between 31 March 2014 and 30 November 2015, evaluated the efficacy and safety of sofosbuvir plus ribavirin therapy among treatment-naïve patients with chronic genotype 1 or 3 HCV infection. A total of 117 patients with genotype 1 or 3 HCV infection were randomized 1:1 to receive sofosbuvir 400 mg and weight-based ribavirin (1000 or 1200 mg) daily for 16 or 24 weeks. Among those with genotype 1 infection, the primary efficacy endpoint of sustained virologic response at 12 weeks post-treatment (SVR12) was reported in 90% (95% confidence intervals [CI], 73-98) and 96% (95% CI, 82-100) of patients following 16 and 24 weeks of treatment, respectively. For patients with genotype 3 infection, SVR12 rates were 100% (95% CI, 88-100) and 93% (95% CI, 78-99) after 16 and 24 weeks of therapy, respectively. Adverse events, most of which were mild or moderate in severity, occurred in 69% and 57% of patients receiving 16 and 24 weeks of treatment, respectively. The most common treatment-emergent adverse events were asthenia, headache and cough. Only one patient in the 24-week group discontinued treatment with sofosbuvir during this study. Overall, sofosbuvir plus ribavirin therapy achieved SVR12 rates ≥90% and was well tolerated among treatment-naïve patients with chronic genotype 1 or 3 HCV infection in India.

Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram?

BACKGROUND

Prospective studies have shown that utilising qualitative D-dimers in those with a low Wells pre-test probability (PTP) of pulmonary embolism (PE) have significantly reduced the number of computed tomography pulmonary angiograms (CTPA) being performed. These studies have been based on a PE prevalence of approximately 6% in the low PTP group.

AIM

This study compares the diagnostic approach to PE in the study institution to well-established guidelines. The study also re-examines the cost-benefit analyses of qualitative d-dimers and CTPA in the low PTP group.

METHODS

A retrospective study of 169 consecutive CTPA requested in the emergency department of a major teaching hospital during a 12-month period.

RESULTS

The prevalence of PE was 0% (0/65), 11.7% (9/77) and 0% (0/2) in the low, moderate and high Wells PTP groups respectively, and 6.3% (9/144) overall. PTP was documented in 10 (6.9%) cases, and the qualitative Clearview Simplify D-dimer was only ordered in 33.8% (22/65) of low PTP subjects. The false positive D-dimer rate was 90.2% (37/41). Cost-benefit analysis and assay performance defines a narrow range of low PTP PE prevalence between 1% and 5% for the utilisation of the qualitative D-dimer assay.

CONCLUSIONS

The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared with data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative D-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the D-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of D-dimers when PE prevalence is very low in the low PTP subgroup.

India's first successful intestinal transplant: the road traveled and the lessons learnt

Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India.

A study of acceptability & feasibility of integrating humanities based study modules in undergraduate curriculum

BACKGROUND & OBJECTIVES

The field of medical education in our country remains deeply fragmented and polarised between the biomedical technical domains which are overrepresented and the humanitarian domains which are under-represented within the universe of medical pedagogy. To overcome this imbalance, we designed a module that integrates the two domains in a holistic biomedical and socio-cultural framework with the objective of providing unified field of learning experience to the undergraduate medical students attending rotatory clinical postings in a medical college in New Delhi, India.

METHODS

Undergraduate medical students of 6 th and 8 th semesters were enrolled in humanities based study module (HSM) on voluntary basis for a total duration of six months. During their compulsory rotatory medicine ward posting, they were introduced and exposed to learning bedside experience of HSM with various tools of art and literature in the form of poem, short narratives, paintings, sketches and group discussions to express their feelings about patients' sufferings. Students' feed-back was recorded through an anonymized questionnaire.

RESULT

Of the 235 students, 223 (95%) enrolled themselves voluntarily and 94 per cent (210 of 223) of them completed the total six month duration of the study module. Seventy three per cent of the students found HSM effective in improving their affective motivational behavior, 82 per cent found it effective in motivating them to learn more about core medical subjects, and 85 per cent wanted its continuation as part of medical curriculum.

INTERPRETATION & CONCLUSIONS

The positive response of the students towards the HSM was an indicator of the potential for integrating the module within the undergraduate medical curriculum.

A new explanation for recessive myotonia congenita: exon deletions and duplications in CLCN1

OBJECTIVE

To assess whether exon deletions or duplications in CLCN1 are associated with recessive myotonia congenita (MC).

METHODS

We performed detailed clinical and electrophysiologic characterization in 60 patients with phenotypes consistent with MC. DNA sequencing of CLCN1 followed by multiplex ligation-dependent probe amplification to screen for exon copy number variation was undertaken in all patients.

RESULTS

Exon deletions or duplications in CLCN1 were identified in 6% of patients with MC. Half had heterozygous exonic rearrangements. The other 2 patients (50%), with severe disabling infantile onset myotonia, were identified with both a homozygous mutation, Pro744Thr, which functional electrophysiology studies suggested was nonpathogenic, and a triplication/homozygous duplication involving exons 8-14, suggesting an explanation for the severe phenotype.

CONCLUSIONS

These data indicate that copy number variation in CLCN1 may be an important cause of recessive MC. Our observations suggest that it is important to check for exon deletions and duplications as part of the genetic analysis of patients with recessive MC, especially in patients in whom sequencing identifies no mutations or only a single recessive mutation. These results also indicate that additional, as yet unidentified, genetic mechanisms account for cases not currently explained by either CLCN1 point mutations or exonic deletions or duplications.

Esophageal tuberculosis: role of endoscopic ultrasound in diagnosis

Esophageal involvement by tuberculosis is rare and is commonly secondary to mediastinal lymph nodal involvement. Endoscopic ultrasound (EUS) is a good modality for evaluation of both esophageal wall and mediastinal lymph nodes. The objectives were to study the role of EUS in diagnosing esophageal tuberculosis, to differentiate primary from secondary form, and to assess the response. Retrospective analysis of data over 7 years (i.e. from 2003 to 2009) was used. The study was set in a tertiary care referral institute and focused on patients diagnosed with esophageal tuberculosis. Interventions used included endoscopy, EUS, EUS-FNA (fine needle aspiration) followed by antituberculosis treatment. The main outcome measurements were symptoms, endoscopic features, EUS features, pathological yield, and response to treatment. There were 32 cases of esophageal tuberculosis. The primary symptom was dysphagia, and endoscopy showed ulcers in 18/32 (56.25%) and extrinsic bulge in 20/32 (62.5%) in middle one third of esophagus. EUS showed lymph nodes adjacent to esophageal pathology in all cases. Subcarinal region was the most common site of lymphadenopathy and they were matted, heterogeneous with predominantly hypoechoic center. Histopathology of endoscopic biopsy of ulcers and EUS-FNA of lymph nodes provided the diagnosis of tuberculosis in 27/32 (84.35%). All patients were treated with antitubercular treatment and showed good clinical, endoscopic and endosonographic response. This is a retrospective study, and PCR and culture for Mycobacterium tuberculosis were not done. Esophageal tuberculosis does not appear to be a primary disease and is most likely secondary to mediastinal nodal tuberculosis. A conglomerated mass of heterogeneous with predominantly hypoechoic lymph nodes with intervening hyperechoic strands and foci on EUS appears to be characteristic of mediastinal tuberculosis.

Acetazolamide efficacy in hypokalemic periodic paralysis and the predictive role of genotype

OBJECTIVES

Acetazolamide has been the most commonly used treatment for hypokalemic periodic paralysis since 1968. However, its mechanism of efficacy is not fully understood, and it is not known whether therapy response relates to genotype. We undertook a clinical and genetic study to evaluate the response rate of patients treated with acetazolamide and to investigate possible correlations between response and genotype.

METHODS

We identified a total of 74 genotyped patients for this study. These included patients who were referred over a 15-year period to the only U.K. referral center or to a Chinese center and who underwent extensive clinical evaluation. For all genotyped patients, the response to acetazolamide therapy in terms of attack frequency and severity was documented. Direct DNA sequencing of CACNA1S and SCN4A was performed.

RESULTS

Only 46% of the total patient cohort (34 of 74) reported benefit from acetazolamide. There was a greater chance of benefit in patients with mutations in CACNA1S (31 responded of 55 total) than in those with mutations in SCN4A (3 responded of 19 total). Patients with mutations that resulted in amino acids being substituted by glycine in either gene were the least likely to report benefit.

CONCLUSIONS

This retrospective study indicates that only approximately 50% of genotyped patients with hypokalemic periodic paralysis respond to acetazolamide. We found evidence supporting a relationship between genotype and treatment response. Prospective randomized controlled trials are required to further evaluate this relationship. Development of alternative therapies is required.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy

BACKGROUND AND STUDY AIMS

Patients with suspected tuberculosis without pulmonary lesions and with mediastinal lymphadenopathy often pose a diagnostic challenge. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) cytology is an established modality to evaluate mediastinal and abdominal lesions. The aim of the present study was to evaluate the role of EUS-FNA in isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis.

METHODS

Consecutive patients suspected of having tuberculosis with isolated mediastinal lymphadenopathy were included in a prospective study. Mediastinal lymphadenopathy was diagnosed on a contrast-enhanced computed tomography scan of the chest. Patients with concomitant lung parenchymal lesions were excluded. Previous attempts to diagnose the etiology of lymphadenopathy had failed in 69 % of patients. EUS-FNA was performed on an outpatient basis under conscious sedation. The sensitivity, specificity, and diagnostic accuracy of EUS-FNA were calculated.

RESULTS

A total of 60 consecutive patients (mean age 39.8 years, 58 % males) with mediastinal lymphadenopathy were included. EUS confirmed the presence of mediastinal lymph nodes ranging in size from 8 mm to 40 mm (mean 26 mm) in all patients. EUS-FNA provided an adequate tissue sample in 54 patients during the first examination and repeat EUS-FNA was necessary in six patients. A final diagnosis was obtained by EUS-FNA in 42 patients (tuberculosis in 32, sarcoidosis in six, and Hodgkin's disease in four patients). An additional 14 patients were treated for tuberculosis based on EUS-FNA and clinical features. Mediastinoscopy was required for diagnosis in the remaining four patients. EUS-FNA had an overall diagnostic yield of 93 %, sensitivity of 71 %, specificity of 100 %, and positive predictive value of 100 %.

CONCLUSION

EUS-FNA is an accurate, safe, and minimally invasive modality for evaluating isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis in an endemic area with a high prevalence of tuberculosis.

Incidence and outcome of arthritis in meningococcal disease

Meningococcal outbreaks are a major health concern in Delhi and adjoining regions. Besides acute pyogenic meningitis, meningococcal disease can also manifest as vasculitis, dermatitis and arthritis. To study the frequency, characteristics and long-term outcome of joint involvement in May 2005 meningococcal outbreak in New Delhi, 24 patients with proven meningococcal disease admitted to the hospital from May, 2005 through August, 2005 were studied for occurrence and outcome of joint involvement, and were followed up and evaluated for any complications. The frequency of arthritis was found to be 20%, which is much higher than reported. Diplococci could be identified in the joint aspirate of all 5 patients who developed arthritis. All patients had features of acute septic arthritis which healed without residual deformity following arthrotomy. A significant percentage of patients can still be expected to develop acute septic arthritis in an outbreak of meningococcal meningitis, and a high index of suspicion should be kept for the same. Prompt diagnosis and management will lead to healing without complications in most cases.

Voltage sensor charge loss accounts for most cases of hypokalemic periodic paralysis

BACKGROUND

Several missense mutations of CACNA1S and SCN4A genes occur in hypokalemic periodic paralysis. These mutations affect arginine residues in the S4 voltage sensors of the channel. Approximately 20% of cases remain genetically undefined.

METHODS

We undertook direct automated DNA sequencing of the S4 regions of CACNA1S and SCN4A in 83 cases of hypokalemic periodic paralysis.

RESULTS

We identified reported CACNA1S mutations in 64 cases. In the remaining 19 cases, mutations in SCN4A or other CACNA1S S4 segments were found in 10, including three novel changes and the first mutations in channel domains I (SCN4A) and III (CACNA1S).

CONCLUSIONS

All mutations affected arginine residues, consistent with the gating pore cation leak hypothesis of hypokalemic periodic paralysis. Arginine mutations in S4 segments underlie 90% of hypokalemic periodic paralysis cases.

What causes paramyotonia in the United Kingdom? Common and new SCN4A mutations revealed

OBJECTIVE

To study the clinical and genetic features in a large cohort of UK patients with sodium channel paramyotonia congenita.

METHODS

We conducted a UK-wide clinical and molecular genetic study of patients presenting with a phenotype suggestive of paramyotonia congenita.

RESULTS

We identified 42 affected individuals (28 kindreds). All cases met our core criteria for a clinical diagnosis of paramyotonia congenita. Seventy-five percent of patients (32 patients/20 kindreds) had SCN4A mutations. Twenty-nine subjects from 18 kindreds had exon 22 and 24 mutations, confirming these exons to be hot spots. Unexpectedly, 3 of these subjects harbored mutations previously described with potassium-aggravated myotonia (G1306A, G1306E). We identified two new mutations (R1448L and L1436P). Ten cases (8 kindreds) without mutations exhibited paramyotonia congenita with prominent pain and weakness.

CONCLUSIONS

This study identifies two new mutations, confirms SCN4A as a common cause of paramyotonia congenita in the UK, and suggests further allelic and possibly genetic heterogeneity.

An antidepressant mechanism of desipramine is to decrease tumor necrosis factor-alpha production culminating in increases in noradrenergic neurotransmission

The monoamine theory of depression proposes decreased bioavailability of monoamines, such as norepinephrine (NE), as the underlying cause of depression. Thus, the antidepressant efficacy of NE-reuptake inhibitors such as desipramine is attributed to increases in synaptic concentrations of NE. The time difference between inhibition of reuptake and therapeutic efficacy, however, argues against this being the primary mechanism. If desipramine elicits its therapeutic efficacy by increasing NE release, in turn, increasing activation of the alpha(2)-adrenergic autoinhibitory receptor, then mimicking this increase with an exogenous agonist (clonidine) should support or even enhance the efficacy of the antidepressant. Intriguingly, simultaneous administration of clonidine with desipramine prevented the cellular and behavioral effects elicited by desipramine alone, in both acute and chronic administration paradigms. These results suggest the involvement of additional factor(s) in the mechanism of antidepressant action of this drug. Desipramine administration results in a virtual ablation of neuron-derived tumor necrosis factor-alpha (TNF), thus implicating an essential role of TNF in the therapeutic efficacy of this antidepressant. Additionally, following chronic administration of desipramine, TNF-regulation of NE release is transformed, from inhibition to facilitation. Here, we demonstrate that a transformation in TNF-regulation of NE release in the brain is a key element in the efficacy of this antidepressant. Interestingly, an increase in neurotransmission prior to the antidepressant's effect on TNF production prevents the efficacy of the antidepressant drug. Thus, the efficacy of desipramine is due to decreased levels of TNF in the brain induced by this drug, ultimately modifying noradrenergic neurotransmission.

Genetic alterations in gastric cancers from British patients

Twenty-six gastric carcinoma and matching normal tissue DNAs, which had previously been analyzed for alterations of the APC (adenomatous polyposis coli) and MCC (mutated in colorectal cancer) genes were further investigated for the following genetic alterations: mutation and loss of heterozygosity (LOH) of the p53 gene, replication error (RER) and LOH at 12 microsatellite repeat loci, and mutation of the hMSH2 gene. In addition, 9 of the 26 gastric carcinomas were analyzed for genetic alterations using comparative genomic hybridization (CGH). Somatic mutations of the p53 gene were found to be frequent being detected in 31% of gastric carcinomas while LOH at the p53 locus was observed in 37.5% of informative cases. Loss of wild type p53 allele was detected in the majority (7 of 8) tumors found to be harboring a mutation. In the hMSH2 gene, an intronic 4 base pair insertion at 31 base pairs upstream of the beginning of exon 13 was detected in both tumor and normal tissue from one gastric carcinoma case. RER was detected in 11.5% of gastric carcinomas, at one or more microsatellite repeat loci. Of the 12 microsatellite repeat loci analyzed LOH was most frequently observed at D22S351 (30% informative cases) suggesting that a tumor suppressor gene on 22q may be important in gastric carcinogenesis. In support of this, CGH analysis carried out on 9 of the gastric carcinomas identified loss of chromosome 22 in 5 of these tumors.

Infrequent alterations of the APC and MCC genes in gastric cancers from British patients

We examined 26 gastric carcinomas from British patients for mutations of the APC gene using a single-strand conformation polymorphism (SSCP) and heteroduplex assay in conjunction with the protein truncation test (PTT). In addition, we performed loss of heterozygosity (LOH) analysis of the APC and MCC genes. We detected an inactivating somatic mutation in one gastric tumour. LOH of APC was observed in one of 12 informative cases (8%) and of MCC in two of 20 cases (10%). We thus find that alteration of the APC and MCC genes are infrequent in gastric cancers from the British population. Tumour-suppressor genes on other chromosomes must play a more significant role in the development of these tumours.

Biliary obstruction due to pancreatic insulinoma

Pancreatic insulinomas are rare tumors and their association with polycystic disease of the liver is uncommon. We report here a patient with pancreatic insulinoma with hepatic metastasis and biliary obstruction presenting with neuroglycopenic symptoms and cholestasis on a background of polycystic liver disease.

Rapid detection of rare variants and common polymorphisms in the APC gene by PCR-SSCP for presymptomatic diagnosis and showing allele loss

During the course of screening the 5' half of exon 15 of the APC gene for germline and somatic mutations in two groups of patients, those with the inherited cancer prone syndrome adenomatous polyposis coli (APC) or with sporadic colorectal cancer, we have identified a number of intragenic changes that are not associated with the disease phenotype. Four of these changes are rare variants, each confined to one or two families and not detected in 50 additional unrelated people. Two common polymorphisms, at codon 1493 (exon 15I) and codon 1678 (exon 15J), were extensively investigated and found to be in almost complete linkage disequilibrium not only with each other but with a previously described polymorphism at codon 1960 (exon 15N). The rapid and sensitive single strand conformation assay used provides an efficient method for presymptomatic diagnosis using intragenic variants and was additionally used to show allele loss at the APC locus in sporadic colorectal carcinomas.