High sensitivity C-reactive protein in systemic lupus erythematosus: relation to disease activity, clinical presentation and implications for cardiovascular risk

Measurement of high sensitivity C-reactive protein (hs-CRP), has been used in the assessment of disease activity in numerous rheumatic conditions including systemic lupus erythematosus (SLE). However, the utility of hs-CRP measurement in patients with lupus is uncertain. This study examined if hs-CRP can be used to assess disease activity, severity and cardiovascular risk in SLE. Serum samples from 601 visits of 213 SLE patients and 134 controls were analysed for hs-CRP by nephelometry. Detailed demographic data were obtained from all subjects and medication history and key laboratory parameters were collected. Disease activity was assessed using the SLEDAI. High sensitivity CRP was not associated with disease activity (SLEDAI), number of ACR SLE criteria or presence of any particular organ involvement. hs-CRP levels were significantly correlated with standard cardiovascular risk factors including body weight ( P = 0.0002), hypertension ( P = 0.001), and apolipoprotein A-I ( P < 0.0001). Interestingly an inverse correlation was seen between hs-CRP levels and antimalarial use ( P = 0.0018). Our results suggest that measurement of hs-CRP, though not valuable as marker of disease activity in SLE may be of some use in the assessment of cardiovascular risk. We speculate that antimalarials may help to reduce cardiovascular risk in patients with SLE.

Population ecology of a freshwater turtle Kachuga tentoria near Panchnada (Etawah: U.P.) and its role as water purifier

The present study deals with biology, ecology and population dynamics of freshwater turtle Kachuga tentoria and its role as water purifier. The study area Panchnada is the site, where five important national rivers meet together and is preserving an appreciable population of nine species of fresh water turtles. Kachuga tentoria was located at all the sampling stations surveyed by the authors, and hence selected for the present study. Different activities (nesting, incubation, predation and other reproductive aspects), climatic conditions, habitat, population density and morphometric features were worked out in detail. A time bound conservation strategy is needed to save this species from extinction. In situ conservation will be more helpful for the recruitment of the population of this species. It will help in the "hatch and release programme" to clean different polluted national rivers.

Henry Kunkel, Stephanie Smith, clinical immunology, and split genes

The York Avenue (New York) 'ecosystem' from the 1940s through the 1980s enabled Henry Kunkel to apply new scientific methodology to understanding human disease. Stephanie Smith, a young woman with lupus, was treated at the Rockefeller University Hospital in the 1960s. Studies of her antinuclear antibodies by Kunkel and Eng Tan led to the discovery of a precipitin line specific for lupus, and the responsible antigen was designated Sm (for 'Smith'). This review outlines the history of Sm antigen from an interesting precipitin line to the identification of small nuclear RNA molecules and small nuclear ribonucleoproteins, and subsequently the discovery of RNA splicing. The story illustrates Henry Kunkel's approach to science, emphasizing how 'accidental' clinical observations, in the hands of skilled investigators, can have unexpected and potentially momentous implications.

Neonatal systemic candidiasis in a tertiary care centre

The purpose of this study was to identify infections causing Candida spp. and to examine their susceptibility to antifungal drugs. The study examined 30 isolates of Candida spp. grown from blood culture samples of neonates. Clinical histories revealed that all 30 infants had received systemic broad-spectrum antibiotic therapy, 27/30 were low birth weight, 21/30 suffered from respiratory distress syndrome and 23/30 were preterm. The three species of Candida isolated were Candida albicans (16/30, 53.3%), C. tropicalis (7/30,23.3%), and C. krusei (7/30, 23.3%). Antifungal susceptibility tests against fluconazole and amphotericin B were done based on the NCCLS guidelines for antifungal susceptibility testing. The fluconazole resistance pattern was as follows: 1/16 (6.25%) strain of C. albicans was susceptible, 12/16 (75%) strains were dose dependent susceptibles, and 3/16 (18.75%) were resistant to fluconazole. Among Candida tropicalis, 2/7(29%) strains were susceptible, 4/7 (55.5%) dose dependent susceptible and 1/7 (14.5%) were resistant. All strains of C. krusei were resistant to fluconazole. There was no resistance to amphotericin B.

Symptomatic congenital syphilis presenting at birth

We report here a case of congenital syphilis presenting in a newborn infant at birth. A negative infant VDRL test, pseudoparesis and more notably, joint swellings (arthritis) were features seen uncommonly. Florid skeletal involvement, which is rarely seen in the early neonatal period, prompted us to draw attention to the varied presentation of this disease, rightly referred to as the "master masquerader".

Leishmania species, drug unresponsiveness and visceral leishmaniasis in Bihar, India

Sixteen isolates obtained, in January 1998-December 1999, from splenic aspirates from sodium stibogluconate-resistant cases of visceral leishmaniasis (VL; Indian kala-azar) and drawn from different districts of Bihar (India) were identified as Leishmania donovani. By isoenzyme analysis, all the strains were found identical to the WHO reference strain L. donovani MON-2 and differed from L. tropica MON-5. This study suggested that resistant cases of VL in Bihar were caused by L. donovani and not by L. tropica. No new strain responsible for drug unresponsiveness emerged during this period and other cause or causes of emergence of drug resistance should be sought. All the patients were cured with amphotericin B.

The effect of lower limb passive movement on lung function

This study examined the effects of ankle passive movement on lung function in healthy adults. A pre-test post-test experimental design was used. Passive plantar and dorsiflexion of the ankle were performed at 60 repetitions per minute on 60 healthy subjects in the supine position. Lung function at rest was compared to that during passive movements. The results indicated that all measured parameters including the breathing frequency, tidal volume, minute ventilation, oxygen consumption and carbon dioxide output, increased significantly during passive movements as compared to those at rest. The authors conclude that passive movements elicit a significant ventilatory increase in healthy human subjects. The effect of passive movements in the treatment of unconscious or diseased individuals should be investigated.

Amphotericin B deoxycholate treatment of visceral leishmaniasis with newer modes of administration and precautions: a study of 938 cases

Out of 938 parasitologically confirmed patients with visceral leishmaniasis treated with amphotericin B (1 mg/kg bodyweight daily infused in 2 h for 20 days), 935 were cured clinically, 933 parasitologically and 931 ultimately (no relapse within 6 months). Two parasitologically 'not cured' and 4 relapsed patients were cured with 25 infusions, and 1 with double relapse with 30 infusions. The treatment was started only when serum haemoglobin reached 5 g/dL, serum electrolyte imbalance was corrected and sodium stibogluconate-induced myocardial damage stabilized after 10 days' rest. Bronchopneumonia, cardiac failure and acute renal failure caused the death of 1 patient each. Nightblindness, angular stomatitis, neuritis, and petechial haemorrhages improved with appropriate treatment; 2 patients were given blood transfusion for post-treatment anaemia. Nausea and anorexia, and changes in serum creatinine and potassium, became normal in 2 weeks. Immediate withdrawal of the drug and restart after 10 days cured 2 patients who developed acute renal failure. Infusion-related toxicities--shivering, rigor and fever--were minimized but not eliminated by prior administration of hydrocortisone. Tuberculosis and visceral leishmaniasis were treated concurrently. Four pregnant patients were successfully treated without harmful effects on mother and child. It was concluded that the dosage of amphotericin B used was an effective and well-tolerated regimen and achieved 99% cure. Toxicity could be minimized with some precautions. All unresponsive and relapsed patients responded to more amphotericin and no resistance to the drug was seen.

Profiling of human leukocyte antigens in Eales' disease

Eales' disease is a primary retinal perivasculitis of an undetermined etiology seen predominantly in the Indian subcontinent and rarely in the West. Strong HLA association has been proven in retinal vasculitis of Behcet's disease. HLA association of Eales' disease is unknown and therefore the present study was undertaken to determine the same. The frequency of 30 HLA antigens (9 HLA-A antigens, 10 HLA-B antigens, 3 HLA-C antigens, 7 HLA-DR antigens and 1 HLA-DQ antigen) was studied by standard micro-lymphocytotoxicity test in 57 patients with Eales' disease and 50 age and sex-matched normal persons as controls. Both the patients and controls underwent complete ocular and clinical examinations and laboratory investigations. Inflammatory diseases similar to Eales' disease were ruled out in the patients before they were enrolled. Statistically significant higher phenotype frequencies of HLA B5 (B51), DR1 and DR4 were observed among patients with Eales' disease as compared to controls. The gene frequency of HLA B5 (B51) in our group of patients and controls was comparable with other earlier studies in the Indian population. The finding of significant association of Eales' patients with positive disequilibrium ( ) haplotypes A3-B44 and A11-B12 may be related to the development of this disease. The presence of the above HLA antigens may be indicative of predisposition to Eales' disease.

A randomized comparison of classical mode of administration of amphotericin B with its newer modes of administration in kala-azar

One hundred thirty parasitologically confirmed cases of kala-azar were randomly divided in two equal treatment groups. Patients in group A were treated by infusion with amphotericin B deoxycholate (ABD), 1 mg/kg day on days 1-20 and the infusion was given in two hours. Patients in group B were treated by an escalating dose of ABD 0.05 mg/kg, 0.1 mg/kg, 0.25 mg/kg, 0.5 mg/kg, 1 mg/kg on days 1-5, respectively and then in the same dosage on alternate days. The infusion was completed in 6 hours. Total dose of 20 mg/kg remaining the same in both the groups, the treatment was completed in 20 days in group A and 43 days in group B. Clinical cure (subsidence of fever, improvement in general well being and regression in the size of the spleen) and parasitological cure (absence of parasites in splenic aspirates at the end of treatment) occurred in all patients in both the groups. Sixty four (99%) patients in each group had not relapsed clinically and parasitologically within 6 months of follow up and were ultimately cured. The two relapsed patients, one in each group were treated with a 20-day course of ABD and were cured. Leukocyte count, haemoglobin, serum albumin increased (P < 0.05) and ESR, spleen and liver size decreased (P < 0.05) at the end of treatment and follow up. Adverse events were similar in both the groups. The minimum cost of treatment estimated was Rs. 14,500 in group B and Rs. 10,000 in Group A. Thus the newer mode of administration was more cost effective.

CONCLUSION

It was concluded that newer mode of administration of amphotericin B was as effective and tolerable as the classical mode of administration and was no more toxic. The newer mode of administration of amphotericin B is more cost effective and puts lesser burden on hospital staff and is recommended for use in kala-azar.

Do the diminishing efficacy and increasing toxicity of sodium stibogluconate in the treatment of visceral leishmaniasis in Bihar, India, justify its continued use as a first-line drug? An observational study of 80 cases

Eighty parasitologically confirmed cases of visceral leishmaniasis (kala-azar) in Bihar, India, were treated daily with 20 mg sodium stibogluconate/kg for 30 days, to assess the current efficacy and toxicity of this 30-day regimen. Clinical and parasitological cure was obtained in 48 (60%) of the patients. However, 26 (33%) patients did not respond to the first course of treatment (primary unresponsiveness), two relapsed after initial clinical and parasitological cure, and two were withdrawn from the study (one on day 6 of treatment because of cardiotoxicity in the form of supraventricular tachycardia and the other on day 24 because of severe loss of appetite). All 30 patients who were not entirely cured with sodium stibogluconate were successfully treated with amphotericin B. Electrocardiographic changes occurred in many of the patients as the result of treatment with sodium stibogluconate. Diminution in the height of the T wave was seen in 32 (40%), inversion of the T wave (Minnesota code 5-1, 5-2) in seven (9%), elevation of the ST segment (Minnesota code 4-1) in three (4%), prolonged QT interval (compared with baseline findings) in six (8%), and diminution in the height of the P, R and T waves in two (3%). Cardiac arrhythmia occurred in five patients (6%), supraventricular arrhythmia (coarse atrial fibrillation) occurred in one patient and ventricular tachycardia, ventricular fibrillation, torsade de pointes and multifocal ventricular ectopics occurred in the four patients (5%) who died of cardiotoxicity. Minor side-effects, such as pain at the site of injection (two cases), mild diminution in appetite (12 cases), metallic taste in mouth (six cases), and joint pain (two cases), were also observed. It was concluded that the efficacy of sodium stibogluconate in the study area has declined over the years and that its toxicity has increased. A more efficacious, safer and cheaper, alternative drug is required as the first line of treatment of kala-azar.

Amphotericin B is superior to sodium antimony gluconate in the treatment of Indian post-kala-azar dermal leishmaniasis

Parasitologically confirmed cases of post-kala-azar dermal leishmaniasis (PKDL) were treated by infusion with amphotericin B deoxycholate (ABD; 1 mg/kg.day on days 1-20, 21-40 and 61-80) or by intramuscular injection with sodium antimony gluconate (SAG; 20-day courses at 20 mg/kg day, with 20-day, drug-free intervals). Of the 11 patients given ABD, all were cured with the three courses, none relapsed in 12 months of follow-up, all developed mild adverse effects (shivering and fever) because of the infusion, five lost their appetites, and three showed increases in their serum creatinine concentrations (although none exceeded 'normal' limits). In contrast, only seven (63%) of the 11 patients given SAG were considered treatment successes (improvement in lesions by the end of the third course) and these took six courses (two cases), nine courses (four cases) or 10 courses (one case) to cure completely. Two of the patients given SAG developed arthralgia and two others developed non-specific ST changes in their electrocardiograms (ECG), although their ECG were normal between courses. The better cure rate with ABD was not statistically significant, probably because of the small sample size. However, ABD appears to be a superior to SAG in terms of the speed of response and cure, although it is more expensive and has some nephrotoxicity. As the effectiveness of SAG against PKDL is apparently declining over time and the cost of ABD is prohibitive in poor countries such as India, a safe, cheap and more effective drug for the treatment of PKDL is needed.

Evaluation of lymphocyte proliferation assay to purified protein derivative, enzyme linked immunosorbant assay, and tuberculin hypersensitivity in Eales' disease

The purpose of this study was to evaluate the immunological responses against mycobacterial antigens in Eales' disease. Fifty six patients with Eales' disease and fifty age-and-sex-matched healthy volunteers with normal fundus findings taken as controls, were subjected to Mantoux test, using 2 TU/0.1 ml of purified protein derivative (PPD), lymphocyte proliferation assay to PPD, and ELISA to detect IgM and IgG antibodies against mycobacterial A-60 antigen. The results of Mantoux test and lymphocytes proliferation assay did not differ significantly in the two groups suggesting a similar cellular immune response. The number of individuals with recent exposure/reexposure to tuberculosis (IgM+) was significantly higher among patients. However the number of people with past exposure (IgM-IgG+) was significantly higher among controls. Our study indicates that there are no statistically significant differences in the humoral and cellular immune responses to mycobacterial antigens between the patients with Eales' disease and controls, except for a significantly higher IgM positivity among the patients.

Pattern of uveitis in a referral uveitis clinic in India

This report describes a retrospective study of all new patients in our uveitis clinic between January 1992 and December 1994, undertaken to identify the pattern of uveitis in the Indian subcontinent. A standard clinical protocol, and the naming-meshing system with tailored laboratory investigations were used to arrive at a final uveitic diagnosis. Uveitis comprised 1.5% of new cases seen at the centre. Out of 1,273 uveitis cases, anterior uveitis was the most common type (39.28%), followed by posterior uveitis (28.75%), intermediate uveitis (17.44%), and panuveitis (14.53%). The most commonly affected age group were patients in their forties (23.57%). Uveitis was less common in children below 10 years (3.61%) and in adults over 60 years of age (6.44%). Men (62.21%) were more commonly affected than women (37.79%). Aetiology remained undetermined in 59.31% of cases. Anterior uveitis was most commonly idiopathic (58.6%). The most common cause of posterior uveitis was toxoplasmosis (27.87%), and that of panuveitis was the Vogt-Koyanagi-Harada syndrome (21.08%). A higher incidence of microbiologically proven tubercular uveitis (5 cases), and uveitis due to live intraocular nematode (4 cases), and malaria (1 case), were seen, in contrast to other studies. Only 2 cases of AIDS with ocular lesions were seen. This paper reveals the pattern of uveitis seen at a major referral eye institute in India.