A Case Report of Hereditary Palmoplantar Keratoderma with Esophageal Melanosis

A 70-year-old man, a known case of diabetes mellitus since 10 years ago, presented with lower limb swelling and dyspnea on exertion for one month and dysphagia to solids associated with early satiety for 2 weeks. The patient had palmoplantar keratosis (PPK), which was present since birth with a similar family history. The patient was admitted to rule out esophageal malignancy. Upper gastrointestinal gastroscopy revealed esophagitis and esophageal melanosis with gastric mucosal erythema. Biopsies samples were taken. Histopathological examination revealed reflux esophagitis and chronic active Helicobacter pylori gastritis with no evidence of malignancy. His symptoms improved following H. pylori eradication and treatment for coronary artery disease and heart failure. The patient was advised of regular follow-up as he had risk factors for the development of esophageal melanoma or squamous cell carcinoma.

Comparison of Fasting Insulin Level, Homeostatic Model of Insulin Resistance, and Lipid Levels between Patients with Primary Hypertension and Normotensive Subjects

BACKGROUND

Hyperinsulinemia and insulin resistance occurs in obese patients with primary hypertension independent of diabetes and obesity. This study was aimed at assessing serum fasting insulin levels, the homeostatic model assessment for insulin resistance (HOMA-IR), and serum lipid levels in non-obese patients with primary hypertension when compared to normotensive subjects.

METHODS

This observational study comprised 100 patients over 18 years of age, divided into two groups. The hypertensive group comprised non-obese patients with primary hypertension (n=50); the normotensive group comprised normotensive age- and sex-matched individuals (n=50). Patients with diabetes, impaired fasting glucose, obesity, and other causative factors of insulin resistance were excluded from the study. Serum fasting insulin levels and fasting lipid profiles were measured, and insulin resistance was calculated using HOMA-IR. These data were compared between the two groups. Pearson's correlation coefficient was used to assess the extent of a linear relationship between HOMA-IR and to evaluate the association between HOMA-IR and systolic and diastolic blood pressures.

RESULTS

Mean serum fasting insulin levels (mIU/L), mean HOMA-IR values, and fasting triglyceride levels (mg/dL) were significantly higher in the hypertensive versus normotensive patients (10.32 versus 6.46, P<0.001; 1.35 versus 0.84, P<0.001; 113.70 versus 97.04, P=0.005, respectively). The HOMA-IR levels were associated with systolic blood pressure (r value 0.764, P=0.0005).

CONCLUSION

We observed significantly higher fasting insulin levels, serum triglyceride levels, and HOMA-IR reflecting hyperinsulinemia and possibly an insulin-resistant state among primary hypertension patients with no other causally linked factors for insulin resistance. We observed a significant correlation between systolic blood pressure and HOMA-IR.

Role of secondary sepsis in COVID-19 mortality: Observations on patients with preexisting diabetes mellitus and newly diagnosed hyperglycemia

Diabetics who develop severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) are more likely to have severe disease, higher odds of intensive care requirement and mortality. Fifteen percent of patients have new onset hyperglycemia. We studied the comparative outcomes between prior DM, newly detected hyperglycemia and assessed role of secondary sepsis on mortality. RWe performed a r etrospective study of confirmed SARS-CoV-2 patients at a tertiary care hospital in Chennai, India. Patients were divided as 2 groups (Group 1: With preexisting diabetes mellitus, Group 2: With newly diagnosed hyperglycemia due to newly detected diabetes mellitus or non-diabetic hyperglycemia. Clinical and laboratory data was analysed. Two hundred and thirty eight patients had prior-diabetes mellitus (Group 1) and 40 had newly diagnosed hyperglycemia (Group 2). Thirty four of group 1 and 7 of group 2 patients required intensive care. Mean capillary blood glucose (MCBG) during hospital stay was 207 mg/dl (Group 1) and 192 mg/dl (Group 2). Twentysix patients (9.3%) had secondary sepsis of which sixteen died. Logistic regression identified secondary sepsis(p<0.0001), elevated D-dimer >6 fold (p= 0.0001), elderly p=0.0045), male (p=0.0006), NLR >5 (p=0.01),serum creatinine ≥2 mg/dl (p=0.0004), FiO2 requirement >0.6 in first 48 hours (p=0.001) as mortality predictors.Our study observed a 14.38 % prevalence of newly diagnosed DM or non-diabetic hyperglycemia. Secondary sepsis and >6 fold elevation in D-dimer were strong predictors of mortality. Steroid use possibly contributed to secondary sepsis. Early identification and aggressive management of secondary sepsis are necessary for diabetics.

Rare Presentation of Isolated Spontaneous Bacterial Empyema without Concomitant Ascites in a Patient with Cirrhosis

In decompensated cirrhosis, massive ascites and pleural effusion (hepatic hydrothorax) can be complicated by infection, which manifests either as spontaneous bacterial peritonitis (SBP) or spontaneous bacterial empyema (SBE). SBE is a distinct and often underdiagnosed complication having different pathogenesis and treatment strategy when compared with parapneumonic empyema. Hepatic hydrothorax in the absence of ascites is rare in patients with cirrhosis. The occurrence of SBE without SBP or ascites is even more of a rarity in cirrhosis and carries great morbidity and mortality. Here we report a case of an elderly female patient with cirrhosis (Child-Pugh Class B) who had unusual features of isolated right-sided hepatic hydrothorax without clinically evident ascites and was later diagnosed as having SBE based on imaging of the thorax, pleural fluid analysis, and cultures. The patient was initially treated conservatively with antibiotics, and diuretics, and later pigtail insertion and drainage was done.

Prevalence, Pattern and Functional Outcome of Post COVID-19 Syndrome in Older Adults

Introduction COVID-19 pandemic has been shown to produce high infection rates, significant morbidity and mortality among older adults. A significant proportion of people who have recovered from acute COVID-19 illness seem to suffer from post COVID-19 syndrome. Post COVID-19 syndrome is thought to be a multisystem disease involving physical, functional, mental and psychological domains. This analysis tries to estimate the prevalence, pattern and functional outcomes of post COVID-19 syndrome in hospitalized older adults. Methods A prospective cohort study was done on 279 older adults who were discharged from our centre between August 1st, 2020 and November 30th 2020. Information was collected through a telephonic interview after 90 days of discharge from the hospital using a standard questionnaire by a trained physician. Collected data were analyzed with IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY). Results After 90 days of recovery, the most common symptoms prevalent in the study population were fatigue (8.9%) followed by cough (4.3%), breathlessness (1.8%), dizziness (1.4%), myalgia (1.1%), loss of smell and taste (0.8%) and chest discomfort (0.7%). The prevalence of risk of anxiety in the study population after 90 days of recovery was 7.5% while that of risk of depression was 12.2%. After 90 days of recovery, 66 (23.6%) patients reported the presence of at least one clinical feature while 9.3% had two or more clinical features. On comparing the mean activities of daily living (ADL) 5.58 (.795) and mean instrumental activities of daily living (IADL) 5.84 (1.49) before the illness and 90 days following recovery there was no statistical difference for the study population. Conclusion The prevalence of post COVID-19 syndrome in older adults is about 9.3%. The most common symptoms reported by older adults after 90 days following recovery were fatigue followed by cough and breathlessness. Most older adults retained their baseline functional status after 90 days of recovery from acute COVID-19.

Course of COVID-19 Based on Admission D-Dimer Levels and Its Influence on Thrombosis and Mortality

Background

Arterial and venous thrombosis is one of the major complications of coronavirus disease 2019 (COVID-19) infection. Studies have not assessed the difference in D-dimer levels between patients who develop thrombosis and those who do not.

Methods

Our study retrospectively assessed D-dimer levels in all virus confirmed hospitalized patients between May to September, 2020. Patients were divided into three groups: group 1 with normal D-dimer of < 0.5 µg/mL, group 2 with elevation up to six folds, and group 3 with more than six-fold elevation. Statistical analysis was done using SPSS software 23.0.

Results

Seven hundred twenty patients (group1 (n = 414), group 2 (n = 284) and group 3 (n = 22)) were studied. Eight thrombotic events were observed. Events were two with stroke, two non-ST elevation myocardial infarction and one each of ST elevation myocardial infarction, superior mesenteric artery thrombosis with bowel gangrene, arteriovenous fistula thrombus and unstable angina. No significant difference (P = 0.11) was observed between median D-dimer levels among patients who developed thrombosis (1.34) and those who did not develop thrombosis (0.91). Twenty-nine patients died. The adjusted odds of death among those with a six-fold or higher elevation in D-dimer was 128.4 (95% confidence interval (CI): 14.2 - 446.3, P < 0.001), while adjusted odds of developing clinical thrombosis was 1.96 (95% CI: 0.82 - 18.2, P = 0.18).

Conclusions

Our study observed a 1.1% in-hospital incidence of clinical thrombosis. While, a six-fold elevation in D-dimer was significantly associated with death; the same was not a strong predictor of thrombosis; an observation which implies that dose of anticoagulation should not be based on absolute D-dimer level.

Masquerading Guillain-Barré syndrome: uncommon, in-hospital presentation of Miller-Fisher syndrome shadowed by secondary diseases

Presentation of severe pain syndromes prior to onset of motor weakness is an uncommon but documented finding in patients with Guillain-Barré syndrome (GBS). Sciatica in GBS is a difficult diagnosis when patients present with acute radiculopathy caused by herniated disc or spondylolysis. A middle-aged woman was admitted for severe low back pain, symptomatic hyponatraemia, vomiting and constipation. On further investigation, she was diagnosed with radiculopathy, and appropriate treatment was initiated. Brief symptomatic improvement was followed by new-onset weakness in lower limbs, which progressed to involve upper limbs and right extraocular muscles. With progressive, ascending, new-onset motor and sensory deficits and laboratory evidence of demyelination by Nerve Conduction Study, a diagnosis of variant GBS was made. She was treated with intravenous immunoglobulin 2 g/kg over 5 days. The presentation of severe low back pain that was masking an existing aetiology and possible dysautonomia and the unilateral right extraocular muscles instead of bilateral make our case unique and rare.

Poststreptococcal Glomerulonephritis without Hypertension in a Patient with Concealed Skin Lesions

Poststreptococcal Glomerulonephritis (PSGN) is an acute inflammation of renal glomerular parenchyma and is sequelae of pharyngitis or skin infection caused by nephritogenic strains of group A beta-Haemolytic Streptococcus. PSGN is conventionally diagnosed based upon clinical findings and demonstration of recent streptococcal infection by a positive skin/throat culture or serologic tests. Hereby, authors present a case of PSGN in an 18-year-old normotensive male is reported who presented with anasarca. On evaluation, the patient had subnephrotic range proteinuria without haematuria and normal serum creatinine. Concealed healing skin lesions in the gluteal region, suggestive of impetigo were noted and hence, arrived at the diagnosis of PSGN. He was treated with intravenous antibiotics, following which symptoms improved. Young patients with acute presentation of oedema or proteinuria with possible renal cause warrants thorough head to foot examination for unseen skin lesions in otherwise overlooked areas. PSGN responds promptly with early antibiotic therapy.