Profile of Rheumatological Manifestations in Leprosy in a Tertiary Care Hospital from Himachal Pradesh

The rheumatological manifestations of leprosy occur singly or in varying combinations, particularly during lepra reactions. Despite being third most common, these remain under diagnosed and under reported. This study has been carried out to study the spectrum of rheumatological manifestations in leprosy patients. One hundred consecutive patients of leprosy presenting during January to December 2013 were studied for rheumatological manifestations. Complete hemogram, serum biochemistry, urinalysis, rheumatoid factor, ASO titer, C-reactive protein, ANA, and x-rays for hands, feet, chest and involved joints were performed. These 100 (M:F 66:34) patients aged between 16-80 years had indeterminate (2 patients), TT (4 patients), BT (26 patients), BB (2 patients), and LL leprosy (32 patients). 27 patients had rheumatological manifestations; arthritis involving large or small joints in 23 patients being the commonest. 7 of 24 patients in type-1 lepra reaction had enthesitis in 3 patients and oligoarthritis in 4 patients. Rheumatoid arthritis-like polyarthritis was noted in 19 patients with type-2 reaction. Tenosynovitis, dactylitis, bony changes were also noted. Except for one case, these features were present in patients having lepra reactions. Rheumatoid factor in 14, ANA in 15, C-reactive protein in 45 cases was positive. ASO was positive 34 cases. Symmetrical polyarthritis involving small joints of hands and feet, oligoarthritis, enthesitis and dactylitis are common in leprosy particularly with borderline leprosy, type-2 lepra reaction especially in the presence of positive RAfactor.

Epidemiology of a new focus of localized cutaneous leishmaniasis in Himachal Pradesh

A new focus of localised cutaneous leishmaniasis has emerged along the Satluj River valley in the mountainous region of north west Himachal Pradesh. The main endemic region extends from Pooh subdivision of Kinnaur district to Kumarsain subdivision of Shimla district with adjoining Nirmand subdivision of Kullu District comprising 86 villages. The climate of the affected areas varies from temperate to subtropical. A total of 285 cases were recorded from 1988 to January, 2005. The age of these patients varied from 10 months to 75 years, with 63 children (<12Years), and a male to female ratio of 1: 0.9. The duration of disease was 15 days to 48 months with majority (85%) presenting between 1-6 months. The number of lesions varied from 1-8, and were mostly seen on exposed parts of the body. Morphologically, lesions were asymptomatic, dry, nodular or crusted nodulo-ulcerative plaques. Tissue smear positivity for amastigotes was 43%. The characterization of 14 strains of these Leishmania revealed presence of both Leishmania tropica (n=3) and Leishmania donovani (n=11). Identification of the 42 sandflies collected from the peridomestic environment of the patients, revealed Phlebotomus longiductus - 29, P. major 8, P. kandelaki 2, while 2 remained unidentified. The patients were treated with intralesional sodium stibogluconate and majority showed excellent response.

Cutaneous sporotrichosis in Himachal Pradesh, India

During the period 1990-2002 in Himachal Pradesh, India, 103 new patients with cutaneous sporotrichosis were detected. Lymphocutaneous and fixed cutaneous varieties were the most common and seen in 49% and 43% respectively. Chronic non-specific inflammation without granuloma formation was seen in 46% skin biopsy specimens, 29% showed acute or chronic inflammation and tuberculoid granuloma formation was seen in 25%. In 32% of cases Sporothrix schenckii growth was seen on Sabouraud glucose agar. A saturated solution of potassium iodide was used as first-line treatment and in 93% patients healing of lesions occurred in 4-32 weeks (average 8.7 weeks) without significant side-effects. Itraconazole, used in 12 patients, was highly effective in recommended doses. Rapid healing was seen with higher than previously used doses of fluconazole in one patient who also had unusual exacerbation of lesional inflammation with saturated solution of potassium iodide.

Cutaneous sporotrichosis: an unusual clinico-pathologic and therapeutic presentation

This report presents a number of unusual clinico-histopathologic and therapeutic features in a culture proven case of cutaneous sporotrichosis. These include lymphocutaneous sporotrichosis involving face; its dissemination in an otherwise healthy patient; its histology mimicking cutaneous cryptococcosis; two episodes of severe purulent inflammatory reaction bordering the lesion during therapy with saturated solution of potassium iodide; no therapeutic response to potassium iodide therapy and rapid healing of lesion with high-dose of fluconazole.

Orofacial conidiobolomycosis due to Conidiobolus incongruus

We report here a patient of orofacial conidiobolomycosis presenting with classical centrofacial distribution described typically for Conidiobolus coronatus infection. The culture, however, showed C. incongruus. The mode of infection and its possible correlation with patient's occupation is also discussed.

A new focus of cutaneous leishmaniasis in Himachal Pradesh (India)

This paper highlights a new focus of cutaneous leishmaniasis (CL) in the temperate area of Himachal Pradesh (India), a previously non-endemic area. In this hospital-based study, 38 new cases of CL, acquired indigenously have been detected from 1988-2000. Of these, 26 were from Kinnaur district and 12 from adjoining areas of bordering districts situated along the river: Satluj. There were 18 males and 20 females. They were between 4-75 years of age and had the disease for one month to 2 years at the time of presentation. Face involvement was seen in majority of the patients. Nodulo-ulcerative plaque was the commonest lesion. Muco-cutaneous lesions were seen in four cases. Tissue smears and biopsies were positive for LD bodies in 61.7% and 29.4% cases respectively. Intralesional sodium stibogluconate produced a consistent therapeutic response. The possible mode of its introduction in the region is postulated. The reservoir of infection, identity of the vector at this altitude (9,002,900 meters above sea level) and the strain of leishmania, remain to be identified.

Trichotillomania and trichophagia leading to trichobezoar

A 14-year-old female presented with the complaints of loss of hair, scalp pruritus, and pain in the abdomen. On careful work-up, she was found to have trichotillomania as well as trichophagia. Investigations also revealed a trichobezoar which completely filled the stomach. Hemogram showed moderate hypochromic anemia. Her detailed psychiatric profile showed a few additional features like obsessive hand washing, knuckle cracking, nose picking and body rocking. Her trichobezoar was removed surgically, and she had an uneventful post-operative recovery. She is being maintained on fluoxetine and is doing well. The role of a multi-disciplinary approach to trichotillomania patients is highlighted.

Chromoblastomycosis in India

BACKGROUND

Four patients with chromoblastomycosis are presented. An additional 30 infected Indian patients are reviewed.

RESULTS

These 34 patients ranged in age from 12 to 80 years with a male to female ratio of 5.8 : 1. Onset before the age of 20 years was seen in 24% of cases which was comparatively high. Culture was positive in 72% of cases and sclerotic bodies were observed in 84% of cases. A relatively higher prevalence (15%) of Fonsecaea compacta was observed. Unusual cutaneous sites afflicted were the penile shaft, vulva, and ala of the nose, and unusual extracutaneous spread was seen in the pleural cavity, ileocecal region, laryngotracheal area, and tonsils. Extracutaneous involvement was seen in 24% of cases. Overlapping infection with another fungus, Geotrichum candidum, was seen in one case.

CONCLUSIONS

Combination therapy with two azoles was attempted with some success for clinical cure.

Atypical post-kala-azar dermal leishmaniasis resembling histoid leprosy

An adult male with atypical lesions of post-kala-azar dermal leishmaniasis (PKDL) is described. He had extensive ulcerated noduloplaque lesions on his hands, feet and genitalia. He had been diagnosed and treated for leprosy in the past. He came from an area endemic for kala-azar and leprosy and had a previous history of kala-azar. There was an abundance of Leishman Donovan bodies in slitskin smears and in histopathology sections. There was a good therapeutic response to sodium stibogluconate. An ulcerative variant of PKDL has been described but is extremely rare. Extensive lesions with ulceration have not been described before to the best of our knowledge. The epidemiological significance of the case is discussed.

Tropical pancreatic diabetes in South India: heterogeneity in clinical and biochemical profile

Clinical and biochemical studies were carried out in 33 patients with diabetes secondary to chronic calcific, non-alcoholic pancreatitis (tropical pancreatic diabetes) and in 35 Type 2 (non-insulin-dependent) diabetic patients and 35 non-diabetic subjects. Despite lower body mass indices, only 25% of patients with tropical pancreatic diabetes had clinical evidence of malnutrition. There was no history of cassava ingestion. Mean serum cholesterol concentration was significantly lower in the tropical pancreatic diabetic patients (p less than 0.01) in comparison with the Type 2 diabetic patients or non-diabetic subjects, due to a significantly decreased concentration of LDL cholesterol (p less than 0.01) and VLDL cholesterol (p less than 0.05). Basal and post-glucose stimulated concentrations of serum C-peptide were highest in those pancreatic diabetic patients (n = 11) who responded to oral hypoglycaemic drugs, intermediate in the majority (n = 17), who were insulin dependent and ketosis resistant and negligible in a small sub-group (n = 5) who were ketosis prone. The occurrence of microangiopathy in pancreatic diabetic patients was common and similar to that in Type 2 diabetic patients. Thus, tropical pancreatic diabetes in South India appears to be heterogeneous with respect to level of nutrition, severity of glucose intolerance, B-cell function, response to therapy and the occurrence of microvascular complications.

Impact of cimetidine on the pharmacokinetics of theophylline

The effect of cimetidine on the pharmacokinetics of theophylline was evaluated. Twelve healthy men volunteers participated in this two-way crossover study. Six subjects were initially treated with theophylline (control), and six were treated with cimetidine and theophylline (cimetidine). Sixteen days after the start of the first phase, the subjects were crossed over. Aminophylline equivalent to 2 mg/kg theophylline was dissolved in 100 ml 5% dextrose injection and infused into an antecubital or forearm vein over a 20-minute period. Cimetidine was ingested in 300-mg doses every six hours beginning 48 hours before the theophylline infusion and continued until 48 hours after the infusion. Blood samples were collected periodically for 48 hours, and serum theophylline concentrations were determined by liquid chromatography. Theophylline concentration versus time data were computer fitted to a biexponential equation. Total theophylline clearance (CLtot), apparent volume of distribution (V), and elimination half-life (t 1/2 beta) were calculated. Semilogarithmic plots of theophylline disappearance showed a decrease during cimetidine treatment. Mean theophylline t 1/2 beta increased significantly during cimetidine treatment from 5.9 +/- 1.0 to 7.3 +/- 1.5 hr, and CLtot decreased significantly from 0.065 +/- 0.010 to 0.049 +/- 0.012 liter/hr/kg. Mean V was unchanged. Two subjects failed to exhibit decreased theophylline clearances, and theophylline clearance increased in another subject. Cimetidine was found to slow the clearance of theophylline and to extend its half-life. Daily doses of theophylline may require adjustment in patients requiring the coadministration of cimetidine. Cimetidine should be added with caution, and serum theophylline concentrations should be monitored accordingly.

Pulmonary amyloidoma and hilar adenopathy. Rare manifestations of primary amyloidosis

Three cases of primary intrathoracic amyloidosis are reported. Two of these three patients initially had localized parenchymal pulmonary amyloid tumors (or pulmonary amyloidomas). The third patient developed bilateral enlargement of the hilar lymph nodes as a manifestation of primary amyloidosis. These rare manifestations of primary amyloidosis are illustrated, and their clinical signifiance is discussed. Amyloidoma should be considered in patients with unexplained pulmonary nodules or enlargement of hilar lymph nodes.

Reexpansion pulmonary edema

A case of pulmonary edema following reexpansion of a collapsed lung due to pneumothorax is described and illustrated. The importance of recognizing this relatively uncommon phenomenon is stressed. The development of such edema can be prevented by avoiding application of sudden and excessive negative pleural pressures during the evacuation of a pneumothorax or a pleural effusion. The edema generally occurs in a lung that has been collapsed for more than three days. The importance of the duration of pulmonary collapse in the causation of edema is demonstrated in this patient.

The value of fiberoptic bronchoscopy in the management of pulmonary collapse

Nineteen fiberoptic bronchoscopic procedures were performed on ten patients for the treatment of pulmonary collapse. All but two patients were being treated for severe, life-threatening nonpulmonary diseases. Thick, tenacious, and, at times, purulent mucous plugs were successfully aspirated from the bronchial passages. Complete to partial radiologic reexpansion of the collapsed pulmonary region was observed following all but one procedure. Significant improvement in blood gas levels was also noticed immediately after the procedure. Bronchoscopic examination in these seriously ill patients did not cause any complications. The therapeutic value of fiberoptic bronchoscopic procedures in patients developing pulmonary collapse due to thick secretions and mucous plugs was demonstrated.

Comparative study of acute effects of albuterol and isoproterenol sulphate aerosols in bronchial asthma

Albuterol, a new bronchodilator drug known to cause beta2-adrenergic receptor stimulation, was compared with isoproterenol sulphate for their pulmonary and cardiovascular effects in patients suffering from bronchial asthma. In a double-blind manner 24 patients received as aerosol 170 micrograms of Albuterol or 150 micrograms of Isoproterenol or placebo on three different days. Spirometric, plethysmographic, heart rate and blood pressure measurements were made at 1, 5, 15, 30, 60, 90, 120, 300 and 360 minutes after drug inhalation. Baseline values for the various indices were not significantly different before administration of the drugs. Results demonstrate that Albuterol is an effective bronchodilator and its bronchodilating effect is significantly superior and of longer duration than that of Isoproterenol. Albuterol did not produce any significant changes in blood pressure and pulse rate, thus confirming its selectivity for beta2 receptors.

The effect of chronic exposure to tobacco smoke on the antibacterial defenses of the lung

To evaluate the effects of cigarette smoking on the host defenses of the lung, male CD rats were exposed to fresh whole smoke for up to 60 consecutive days. Intrapulmonary deposition of smoke and animal exposure levels, quantified with decachlorobiphenyl and other smoke tracers, indicated a daily cigarette exposure equivalent to approximately a pack and a half per day in man. Pulmonary alveolar macrophage function in situ was quantified by the inactivation of an aerosolized challenge of Staphylococcus aureus six hours after inoculation. Controls (n=120) inactivated 88.8+/-0.64% of the staphylococci. Exposure to whole smoke did not impair intrapulmonary antistaphylococcal defenses, with inactivation rates of 89.8+/-0.97% (n=49) and 89.1+/-0.46% (n=74) at 30 and 60 days, respectively. Inactivation distribution frequency analysis in controls revealed that 7% of animals had inactivation values greater than two standard deviations from the mean. With prolonged exposure mean with less skewing towards the abnormal. Alveolar macrophages harvested from smoked animals were comparable in viability and in vitro antistaphylococcal activity to controls, appeared to be metabolically activated and had specific stereologic ultrastructural alterations. These studies indicate that chronic exposure to tobacco smoke does not impair, and in fact may stimulate, the host defenses of the lung, as evaluated by in vivo and in vitro pulmonary alveolar macrophage function.

Structure of L-arabinose-binding protein from Escherichia coli at 5 A resolution and preliminary results at 3.5 A

The three-dimensional crystal structure of the L-arabinose-binding protein from E. coli, an essential component in the active transport of L-arabinose, has been solved at 5 A resolution using the method of multiple isomorphous replacement. Five heavy atom derivatives were used. A preliminary 3.5 A electron density map has also been calculated. The results indicate that the molecule is ellipsoidal with approximate dimensions 68 A X 38 A X 30 A. Two similar domains within the molecule (which is a single polypeptide chain) are related by an approximate noncrystallographic rotation-translation axis. This relationship involves approximately 20% of the structure.