Short-term Changes in Urine Beta 2 Microglobulin Following Recovery of Acute Kidney Injury Resulting From Snake Envenomation

Introduction

Urine β2 microglobulin (β2m) is a validated marker to diagnose sepsis and toxin-related acute kidney injury (AKI). In the current study, we used urine β2m as a potential marker to identify persistent tubular dysfunction following a clinical recovery from snake venom–related AKI.

Methods

A total of 42 patients who developed AKI following hemotoxic envenomation were followed up for a period of 6 months. Urine albumin excretion, estimated glomerular filtration rate (eGFR), and urine β2m levels were measured at 2 weeks, 3 months, and 6 months following discharge.

Results

At the end of 6 months of follow-up, 6 patients (14.3 %) progressed to chronic kidney disease (CKD) (eGFR < 60 ml and/or urine albumin excretion > 30 mg/d). The urine β2m levels were 1590 μg/l (interquartile range [IQR] 425–5260), 610 μg/l (IQR 210–1850), 850 μg/l (IQR 270–2780) at 2 weeks, 3 months, and 6 months, respectively (P = 0.020). The levels of urine β2m in the study population at the end of 6 months remained significantly higher compared with the levels in healthy control population (850 μg/l [IQR 270–2780] vs. 210 μg/l [IQR 150–480]; P = 0.001). The proportion of patients with urine β2m levels exceeding the 95th percentile of control population (>644 µg/l) during the 3 follow-up visits were 70.7% (n = 29), 48.8 % (n = 20), and 51.2% (n = 21). Similar trends were noticed in a sensitivity analysis, after excluding patients with CKD.

Conclusions

Urine β2m levels remain persistently elevated in approximately half of the individuals who recover from AKI due to snake envenomation.

Vitamin D deficiency in patients with tuberculous meningitis and its relationship with treatment outcome

SETTING

Data on vitamin D deficiency in tuberculous meningitis (TBM) and its relationship with treatment outcomes are limited. Some of the beneficial effects of vitamin D might be mediated through interleukin-1β (IL-1β).

OBJECTIVE

To assess the frequency of vitamin D deficiency among TBM patients, its association with treatment outcomes and correlation between vitamin D and IL-1β levels in cerebrospinal fluid (CSF).

DESIGN

We prospectively studied a consecutive sample of human immunodeficiency virus-negative patients with TBM treated at a hospital in southern India. We defined good outcome as survival without severe neurological disability. Serum total 25-hydroxy vitamin D (25[OH]D) and IL-1β levels in CSF were estimated on pretreatment samples.

RESULTS

We studied 40 patients with TBM; 22 (55%) patients had stage 3 disease. Treatment outcome was poor in 21 (53%) patients: 15 (38%) patients died and 6 (15%) had severe neurological disability. The overall mean serum 25(OH)D level was 32.30 ± 16.38 ng/ml. Ten (25%) patients had vitamin D deficiency (<20 ng/ml), and 12 (30%) patients had vitamin D insufficiency (20-30 ng/ml). However, pretreatment serum 25(OH)D levels did not differ significantly by outcome (good vs. poor outcome: 28.30 ± 14.96 vs. 35.92 ± 17.11 ng/ml, P = 0.141). Moreover, IL-1β levels in CSF did not correlate with serum 25(OH)D levels (Spearman's ρ 0.083, P = 0.609).

CONCLUSION

Vitamin D deficiency/insufficiency is common among patients with TBM. However, serum 25(OH)D levels are not associated with IL-1β levels in CSF or treatment outcome.

Occupational exposure and tuberculosis among medical residents in a high-burden setting: an open-cohort study

SETTING

Postgraduate (PG) residency programme of a tertiary care teaching hospital in southern India.

OBJECTIVE

To estimate the incidence of tuberculosis (TB) among PG residents, determine the frequency of exposure to infectious TB patients and assess whether particular specialties were associated with higher risk of exposure and incident TB.

DESIGN

We assembled an open cohort of PG residents who were on the academic rolls for more than 3 months at any time between December 2011 and January 2013. We collected data both retrospectively and prospectively using two surveys-an entry survey at study initiation or entry into the cohort, and an exit survey at residency completion or study closure.

RESULTS

Among 398 PG residents enrolled in the study, we identified five cases of incident TB during a cumulative follow-up period of 10 962 person-months. The incidence rate was 547 per 100 000 person-years, which was 3.1 times the incidence in the general population. Nearly two thirds (n = 257, 65%) of the residents were exposed to at least one infectious patient. Across the three specialty-based risk strata, there was an ordered increase in the median number of exposures (P < 0.001) and evaluation for presumptive TB (P = 0.024), as well as a trend towards higher incident TB.

CONCLUSION

TB incidence is significantly higher among PG residents than in the general population.

Clinical spectrum and outcomes of crescentic glomerulonephritis: A single center experience

There is limited data on the etiology, clinical and histopathological spectrum and outcomes of crescentic glomerulonephritis (CrGN) in adult Indian population. This prospective study was done to evaluate the etiology, clinicohistological patterns and predictors of outcome of CrGN in South Indian population. All the patients received standard protocol based immunosuppression in addition to supportive care. Immune-complex glomerulonephritis (ICGN) was the most common etiology (n = 31; 77.5%) followed by pauci-immune glomerulonephritis (PauciGN; n = 8; 20%) and anti-glomerular basement membrane disease (n = 1; 2.5%). The most common etiology of ICGN was IgA nephropathy (n = 11; 27.5%) followed by lupus nephritis (n = 7; 17.5%) and post-infectious glomerulonephritis (PIGN) (n = 7; 17.5%). The patients with PauciGN were significantly older compared to those with ICGN (44.5 ± 15 years vs. 31.8 ± 11 years; P = 0.01). The patients with PauciGN presented with significantly higher serum creatinine (9.7 ± 4.4 vs. 6.6 ± 3.3 mg/dl; P = 0.03). The histopathologic parameters of ICGN and PauciGN were comparable except for a higher proportion of sclerosed glomeruli in ICGN. At the end of 3 months follow-up, only two patients went into complete remission (5.4%). Majority of the patients had end-stage renal failure (48.6%) and were dialysis dependent and seven patients (18.9%) expired. There was no signifi difference in the renal survival (10.9 ± 1.9 vs. 9.6 ± 3.3 months) or patient survival (17.5 ± 2.1 vs. 17.3 ± 4.3 months). The parameters associated with adverse outcomes at 3 months were hypertension (odds ratio [OR]: 0.58; confidence interval [CI]: 0.36–0.94), need for renal replacement therapy (OR: 0.19; CI: 0.04–0.9), serum creatinine at admission (P = 0.019), estimated glomerular filtration rate (P = 0.022) and percentage of fibrocellular crescents (P = 0.022).

Spontaneous nontraumatic subarachnoid hemorrhage without cerebrovascular malformations in a maintenance hemodialysis patient

Nontraumatic subarachnoid hemorrhage (SAH) in a dialysis patient is an uncommon occurrence and is often associated with high mortality. We report for the first time in India, a case of spontaneous nontraumatic, nonaneurysmal SAH without any cerebrovascular malformation in a maintenance hemodialysis patient, following a session of hemodialysis. The dialysis prescription needs to be modified in these patients, in order to prevent worsening of cerebral edema and progression of hemorrhage. Where available, continuous forms of renal replacement therapies, with regional anticoagulation seem to be the best option for such patients, till neurologic stabilization is achieved.

Efficacy of Turmeric as Adjuvant Therapy in Type 2 Diabetic Patients

It is known that there is a significant interplay of insulin resistance, oxidative stress, dyslipidemia, and inflammation in type 2 diabetes mellitus (T2DM). The study was undertaken to investigate the effect of turmeric as an adjuvant to anti-diabetic therapy. Sixty diabetic subjects on metformin therapy were recruited and randomized into two groups (30 each). Group I received standard metformin treatment while group II was on standard metformin therapy with turmeric (2 g) supplements for 4 weeks. The biochemical parameters were assessed at the time of recruitment for study and after 4 weeks of treatment. Turmeric supplementation in metformin treated type 2 diabetic patient significantly decreased fasting glucose (95 ± 11.4 mg/dl, P < 0.001) and HbA1c levels (7.4 ± 0.9 %, P < 0.05). Turmeric administered group showed reduction in lipid peroxidation, MDA (0.51 ± 0.11 µmol/l, P < 0.05) and enhanced total antioxidant status (511 ± 70 µmol/l, P < 0.05). Turmeric also exhibited beneficial effects on dyslipidemia LDL cholesterol (113.2 ± 15.3 mg/dl, P < 0.01), non HDL cholesterol (138.3 ± 12.1 mg/dl, P < 0.05) and LDL/HDL ratio (3.01 ± 0.61, P < 0.01) and reduced inflammatory marker, hsCRP (3.4 ± 2.0 mg/dl, P < 0.05). Turmeric supplementation as an adjuvant to T2DM on metformin treatment had a beneficial effect on blood glucose, oxidative stress and inflammation.

Successful salvage of thrombosed arterio-venous fistula with thrombolytic therapy using tissue plasminogen activator

A functioning vascular access is crucial to the wellbeing of patients on hemodialysis. Thrombosis is the most common complication of arteriovenous fistula (AVF) resulting in late fistula failure; Its treatment is difficult, and results are often suboptimal. Interventional treatment of AVF thrombosis may not be available all the time, and timely application of an available noninterventional treatment may salvage the fistula. We report the successful treatment of AVF thrombosis using local thrombolytic therapy using tissue plasminogen activator in a patient, for the first time in India.

Medullary sponge kidney and isolated hemihyperplasia

The term hemihyperplasia refers to an enlargement of body parts beyond the normal asymmetry. Hemihyperplasia can be isolated or associated with various well-described malformation syndromes. Medullary sponge kidney (MSK) has been described with isolated and syndromic hemihyperplasia; the actual prevalence is not known The hemi hypertrophy can be so subtle that it may be easily overlooked. MSK need not be limited to the side of hemihyperplasia - most often it is bilateral. Around 33 cases has been reported from different parts of the world of which 15 cases are isolated hemi hyperplasia (IHH), the remaining occurring in the context of various malformation syndromes So far only one case has been reported from India. We report a case of IHH involving right side of the body, recurrent renal stones, incomplete distal renal tubular acidosis hypercalciuria and imaging showing bilateral MSKs.

Gly460Trp polymorphism of the ADD1 gene and essential hypertension in an Indian population: A meta-analysis on hypertension risk

BACKGROUND:

Essential hypertension is a complex genetic trait. Genetic variant of alpha adducin (ADD1) gene have been implicated as a risk factor for hypertension. Given its clinical significance, we investigated the association between ADD1 Gly460Trp gene polymorphism and essential hypertension in an Indian population. Further, a meta-analysis was carried out to estimate the risk of hypertension.

METHODS:

In the current study, 432 hypertensive cases and 461 healthy controls were genotyped for the Gly460Trp ADD1 gene polymorphism. Genotyping was determined by real time PCR using Taqman assay. Multiple logistic regression analysis was used to detect the association between Gly460Trp polymorphism and hypertension.

RESULTS:

No significant association was found in the genotype and allele distribution of Gly460Trp polymorphism with hypertension in our study. A total of 15 case-control studies were included in the meta-analysis. There was no evidence of the association of Gly460Trp polymorphism with hypertension in general or in any of the sub group.

CONCLUSIONS:

We found that the Gly460Trp polymorphism is not a risk factor for essential hypertension in a south Indian Tamilian population. However, the role of ADD1 polymorphism may not be excluded by a negative association study. Further, large and rigorous case-control studies that investigate gene–gene–environment interactions may generate more conclusive claims about the molecular genetics of hypertension.

Polymorphic variants of beta1 adrenergic receptor gene (Ser49Gly & Arg389Gly) in healthy Tamilian volunteers

BACKGROUND & OBJECTIVES

Several studies reported the polymorphisms of beta1-adrenergic receptor gene in healthy volunteers and its influence on cardiovascular disorders. We investigated the genotype and allele frequencies of Ser49Gly and Arg389Gly polymorphism in healthy volunteers of South Indian Tamilian population vis-à-vis other major ethnic groups.

METHODS

The genetic variants were determined by using Taqman 5' nuclease assay- real time PCR analysis in 533 normal healthy volunteers (18-60 yr; M=290; F=243). The allelic discrimination analysis was done by 7700 SDS software.

RESULTS

The estimated genotype and allele frequencies of Ser49Gly and Arg389Gly polymorphism were compared with other major populations. The frequencies of the variant alleles Gly49 and Gly389 were 15.1 and 25.8 per cent respectively.

INTERPRETATION & CONCLUSIONS

Our study shows that interethnic variation exists in the polymorphisms of beta1-adrenergic receptor gene and the results generated in this study might serve as a genetic marker for further studies in Tamilian (South India) population.

Neuroparalysis and ventilatory support in severe tetanus

In severe form of tetanus, even with maximum dose of muscle relaxants, spasms and apnoeic spells may persist and that may be life-threatening. The aim of this study was to assess the effect of neuroparalysing the patients and then providing ventilatory support in bringing about their recovery. Forty-nine adult patients of severe tetanus (Ablett's grade IIIA--6 patients and Ablett's grade IIIB--43 patients) were studied during the period from April, 1993 to February, 1996. Mean period of onset ie, period from trismus to first spasm, in these patients was 24 hours. Patients were neuroparalysed with a bolus dose of 2-4 mg of pancuronium followed by a continuous infusion of 1-2 mg/hour and simultaneously supported with mechanical ventilation until spasms subsided. Fourteen patients (28.6%) survived and rest died. Mean duration of ventilatory support on survived patients was 14.4 days. The commonest complication encountered during ventilatory support was respiratory tract infection observed in 36 patients (73.5%). Commonest cause of death was autonomic imbalance encountered in 15 patients (30.6%). Treatment of choice in severe tetanus should be neuroparalytic ventilatory support. With use of new generation ventilators and better intensive care facility, death in severe tetanus is likely to be very less.

Lymphoplasmacytic lymphoma with IgA paraproteinemia mimicking Waldenstrom's Macroglobulinemia

Central to the diagnosis of Waldenstrom's Macroglobulinemia is the demonstration of bone marrow infiltration by lymphoplasmacytic lymphoma with Ig M monoclonal gammopathy. We describe a patient who presented with a clinical and haematological picture, highly suggestive of Waldenstrom's Macroglobulinemia, but whose serum monoclonal immunoglobulin belonged to Ig A class. Ig A secreting lymphoplasmacytic lymphoma undoubtedly exist but are exceedingly uncommon and their relationship to Waldenstrom's Macroglobulinemia needs to be clarified.

Bone marrow cryptococcosis: a case report

A 35-year-old male presented with fever and bilateral cervical and axillary lymphadenopathy. Peripheral blood film examination revealed thrombocytopaenia. Bone marrow aspiration and trephine biopsy, done for evaluation of thrombocytopaenia and pyrexia showed presence of ill-defined granulomas along with cryptococcal yeast forms. Fine needle aspiration of lymph nodes, cerebrospinal fluid and sputum analyses also showed cryptococci. ELISA for Human Immunodeficiency Virus (HIV) antigen was positive. Granulomas, when found in bone marrow aspiration smears and trephine biopsy, are a valuable histological clue to an opportunistic infection. Disseminated fungal infection such as cryptococcosis should raise the possibility of immunosuppression, especially Acquired Immunodeficiency Syndrome. Bone marrow examination is a useful method of diagnosing opportunistic fungal and mycobacterial infections in patients with fever, anaemia or thrombocytopaenia and underlying HIV infection.

Melioidosis--a report from Pondicherry, South India

Melioidosis is an acute infectious disease caused by a safety-pin-shaped gram-negative bacteria called Burkholderia pseudomallei. Here, we report the first case of melioidosis in a middle aged male agricultural worker, from Pondicherry. The isolation of this organism from subcutaneous nodules on the extensor aspect of his limbs underlines the diversity of its clinical presentation. Difficulty in identifying the organism which mimics any other non-fementing gram-negative bacilli (NFGNB) on cursory examination, highlights the importance of identification of NFGNB in endemic areas for specific treatment and prevention.

Human anthrax in India: urgent need for effective prevention

Anthrax is a zoonotic illness caused by Bacillus anthracis. Sporadic cases continue to be reported from many parts of the world. From India, both sporadic cases and outbreaks are being reported regularly. The Union Territory of Pondicherry (a former French colony) lies on the coast of Bay of Bengal, where the incidence of anthrax is on the rise with 28 cases being detected in the year 1999 and 2000 alone. So far, about 34 human cases have been encountered in this region. Recently, an increase in the number of anthrax cases has been noted in veterinary and human practice in this area. Most cases have occurred in agricultural labourers who gave history of handling animal meat or skin of infected animals. The meningitic form of the disease has a very bad prognosis. Patients with this form of disease died despite treatment with high dose penicillin. The typical bacilli were seen in the CSF in all cases of anthrax meningitis and was diagnostic of the condition. The cutaneous form of illness had a benign course and responded favourably to penicillin treatment. Awareness among clinicians and mandatory reporting of cases to public health departments along with public education will help control morbidity and mortality due to anthrax. Effective immunization of animals is the other important control measure for anthrax.

Influence of type I and type II diabetes mellitus on phenytoin steady-state levels

Phenytoin kinetics was studied in male type I and type II diabetic patients, ten in each group. Age and sex matched epileptic patients receiving phenytoin alone served as control groups. Steady-state concentration of phenytoin was significantly lower in both types of diabetics compared to respective controls. The Vmax and Vmax/Km of phenytoin were significantly increased in type I diabetics. The Vmax was unaltered in type II diabetics but the Vmax/Km was higher in them. Protein binding of the drug was decreased in both groups. It is concluded that phenytoin kinetics is increased in both types of diabetics which may be responsible for the lower steady-state concentration of the drug.

Differential effect of type I and type II diabetes mellitus on antipyrine elimination

Antipyrine elimination was studied in 11 type I and 10 type II diabetic patients and 2 age-matched control groups. After oral administration of antipyrine (15 mg/kg), salivary concentration of the drug was measured at various time intervals by high performance liquid chromatography method. In type I diabetics the clearance rate (CL) and apparent volume of distribution (V) of the drug were significantly higher when compared to corresponding controls. The elimination half-life (t 1/2) remained unaltered. In type II diabetics, the t 1/2 of the drug was increased due to increase in V. There was no significant difference in CL. It is concluded that antipyrine elimination is enhanced in type I diabetics while in type II patients it is unaltered.

Differential effect of type I and type II diabetes mellitus on serum ampicillin levels

Ampicillin elimination was studied in 10 poorly controlled, 6 well controlled type I and 14 poorly controlled type II diabetic patients. Two groups of age-matched healthy volunteers served as controls. After oral administration of ampicillin (500 mg), the poorly controlled type I diabetics had significantly lower serum concentration of the drug when compared to their corresponding healthy controls. The elimination half-life (t1/2) remained unaltered. Their creatinine clearance rate and urinary excretion of the drug were significantly reduced. There was no difference in these parameters between well controlled diabetics and healthy volunteers. The bioavailability data calculated from the urinary recovery of the drug, after oral and i.v. administration, suggested reduced oral absorption in poorly controlled type I diabetic patients. Ampicillin kinetics data of poorly controlled type II diabetic patients were not significantly different from that of the control group. Serum ampicillin levels and urinary excretion of the drug were similar in these groups. It is concluded that serum ampicillin level may be lower in poorly controlled type I diabetics which may be due to reduced absorption of the orally administered drug.

A comparative study of creatinine clearance rate in type I (IDDM) and II (NIDDM) diabetic patients

The endogenous creatinine clearance test was done in 14 Type I and 15 Type II poorly controlled diabetic patients and compared with respective age matched healthy volunteers. Type I diabetics had significantly lower creatinine clearance rate, body mass index and serum albumin levels when compared to their control group. In Type II diabetics these values remained unaltered. Both Type I and Type II diabetics had significantly higher blood sugar and glycosylated haemoglobin levels. The creatinine clearance rate had significant positive correlation with patients' body mass index and serum albumin levels. This suggests that the undernutrition of Type I diabetics may be responsible for the decreased creatinine clearance.

Effect of diabetes mellitus on salivary paracetamol elimination

1. Salivary elimination of paracetamol was studied in nine type I and ten type II diabetics. Ten healthy volunteers served as a control group. 2. A significant increase in the elimination half-life (t1/2) and apparent volume of distribution was observed in type I diabetics compared with controls. Clearance rate (CL) was not significantly altered. 3. In type II diabetics paracetamol elimination t1/2 was significantly increased with a corresponding decrease in CL. Apparent volume of distribution of the drug was not significantly different. 4. Paracetamol elimination t1/2 had significant correlation with fasting blood sugar values.

A study on the neurotoxicity of broxyquinoline and brobenzoxaldine combination in therapeutic doses

The neurotoxicity of a combination of broxyquinoline and brobenzoxaldine (Intestopan Forte, containing 500 mg and 100 mg of the drugs respectively per capsule) was investigated by prospective clinical and electrophysiological studies in patients and volunteer subjects given the drugs in therapeutic doses (two capsules three times a day for 5 days). Of 16 patients with intestinal amoebiasis given the drugs (study A), 13 (81.25%) were cured. Adverse effects were mild and did not affect treatment. No neurological adverse effect was reported. Neurological examinations revealed no abnormality in any patient after treatment. Seven volunteer subjects underwent medical, neurological and ophthalmological examinations, and electrophysiological studies of ulnar and peroneal nerve conduction before and after treatment with the drugs in therapeutic doses (study B). Transient paresthesias were reported by one subject on the fourth day of treatment. No medical, neurological or ophthalmological abnormality was detected in any subject after treatment. There was no significant change in motor nerve conduction velocities. There was a significant (P less than 0.001) increase in the stimulus strength for distal ulnar stimulation and a significant (P less than 0.01) decrease in stimulus duration for proximal and distal ulnar stimulation. No significant changes were seen in the peroneal nerves in these parameters. No qualitative abnormality was seen in the oscilloscopic patterns of nerve conduction after treatment. Literature on the neurotoxicity of the halogenated hydroxyquinolines is reviewed. It is concluded that broxyquinoline and brobenzoxaldine (and probably other halogenated hydroxyquinolines as well) are safe and effective in therapeutic doses; neurotoxicity is unlikely to occur when these drugs are used according to therapeutic recommendations.