The Journal of the Association of Physicians of India最新文献

A 69-year-old gentleman without any previous comorbidities presented with complaints of acute-onset low-grade fever, one episode of loss of consciousness, and weakness of both legs with urinary and stool retention for 1 day. He had an episode of generalized tonic-clonic seizure 3 hours after admission. On examination, he had tachycardia and hypotension; Glasgow Coma Scale (GCS) was E3V2M4, and neurological examination was suggestive of bilateral lower limb upper motor neuron lesion in the shock stage. Blood investigation revealed severe hyponatremia, and magnetic resonance imaging (MRI) with contrast of the dorsolumbar spine revealed longitudinally extensive transverse myelitis (LETM). Blood investigation for antineuromyelitis optica (anti-NMO) antibody was negative. Other investigations revealed low serum osmolality, raised urine osmolality, and spot sodium. Cerebrospinal fluid (CSF) viral panel detected human herpesvirus 6 (HHV6). He was treated with a pulse dose of IV methylprednisolone, hypertonic saline, and IV levetiracetam. He had symptomatic improvement and was discharged with a tapering dose of oral prednisolone. He had a complete recovery after 3 months of regular follow-up. Thus, we report a case of HHV6-induced LETM complicated with cerebral salt wasting syndrome and hyponatremic seizures.

Introduction: Low or abnormal plasma concentrations of anti-tuberculosis drugs can be a major reason for treatment failure or the emergence of drug resistance. Acetylator status, which affects drug metabolism, plays a key role in determining drug bioavailability. This study aimed to perform therapeutic drug monitoring (TDM) of rifampicin and isoniazid and to evaluate the correlation between plasma drug concentrations and acetylator status among Indian patients receiving first-line antituberculosis therapy.

Methods: Plasma concentrations of rifampicin and isoniazid were measured using in-house standardized high-performance liquid chromatography methods, while acetylator status was determined by conventional PCR of NAT2 gene.

Results: Peak concentrations were estimated from 125 patients on first-line tuberculosis (TB) treatment. Among these, 56% exhibited subtherapeutic rifampicin concentrations and 28% had subtherapeutic isoniazid concentrations. Conversely, above normal (potentially toxic) concentrations were seen in 2% and 21% for rifampicin and isoniazid, respectively. Despite receiving the standard TB treatment regimen, only 62% of patients improved clinically, while 38% of patients continued harboring TB signs and symptoms, among which 6 patients (5%) developed rifampicin resistance during the treatment course. About 44% were slow acetylators, followed by 40% intermediate and 16% rapid acetylators. The acetylator status significantly influenced the plasma concentrations of both drugs. Slow acetylators had significantly higher isoniazid concentrations (p = 0.004) and lower rifampicin concentrations (p = 0.01) as compared to rapid acetylators.

Conclusion: Abnormal concentrations of rifampicin and isoniazid are prevalent and a major concern. Acetylator status influences plasma concentrations of rifampicin and isoniazid. Hence, determining acetylator status and performing TDM could be instrumental in optimizing and improving TB outcomes.

Internuclear ophthalmoplegia with ipsilateral horizontal gaze palsy is called one and a half syndrome. There are a number of numerical one and a half spectrum disorders. One such syndrome is nine syndrome, which is characterized by one and a half syndrome, ipsilateral lower motor neuron type facial palsy, and contralateral hemiparesis or hemihypesthesia or hemiataxia. Here we describe a case of nine syndrome with left one and a half syndrome, left lower motor neuron type facial palsy, and right hemiataxia.

Amyloidosis is an extremely rare condition with a variety of symptoms that, in extreme situations, can be fatal. Basically a protein misfolding disorder, it is characterized by deposition of insoluble polymeric protein fibrils in tissues and organs. There are different types of amyloidosis; here, we see a case of secondary amyloidosis, which is usually a consequence of a chronic disease. The case is unique, as there are many research projects showing the link of tuberculosis (TB) and secondary amyloidosis, but it is rarely documented because of extrapulmonary TB, which here is tuberculous lymphadenitis, and also here the patient is younger than the mean age. The clinical manifestations of this disease are seen mainly in the renal system, gastrointestinal system, and reticuloendothelial system. For which the management is mainly supportive, along with treatment of the underlying cause.

We present a case of a patient with undiagnosed myasthenia gravis presenting in myasthenic crisis. In this case, the patient presented primarily with myocardial infarction with nonobstructive coronary arteries and respiratory failure and was later diagnosed to be in myasthenic crisis. The myasthenic crisis was treated with intravenous immunoglobulin (IVIg) and corticosteroids. Given the inadequate response to IVIg and glucocorticoids, the patient was subsequently administered an anti-CD20 monoclonal antibody in the form of rituximab. The patient responded well to rituximab, and her cardiac function subsequently improved.

Background: Dermatophytes, primarily Epidermophyton spp., Trichophyton spp., and Microsporum spp., are responsible for superficial cutaneous mycoses, estimated to affect 20-25% of the people worldwide. The rise of antifungal resistance, especially to terbinafine, has made treating dermatophytosis increasingly difficult. This study aims to assess the clinical and mycological characteristics of dermatophytosis cases and evaluate the in vitro susceptibility of dermatophyte isolates to terbinafine and griseofulvin.

Materials and methods: A total of 118 samples were studied from patients with clinical suspicion of dermatophytosis. The samples were processed for KOH mount and fungal culture for further speciation. Susceptibility to terbinafine and griseofulvin was assessed using the microbroth dilution technique, following the guidelines established by the Clinical and Laboratory Standards Institute (CLSI).

Results: Tinea corporis (57.6%) appeared as the leading symptomatology in our study, followed by tinea cruris (10.2%). KOH positivity was higher (70.3%) compared to positivity by culture (16.9%). Trichophyton mentagrophytes was the predominant species (85%) isolated, followed by Trichophyton violaceum (10%) and Microsporum gypseum (5%). Terbinafine resistance was observed in over 60% of T. mentagrophytes isolates, with moderate resistance detected in T. violaceum. Griseofulvin showed moderate resistance in T. mentagrophytes and higher resistance in T. violaceum.

Conclusion: This study highlights the increased resistance of T. mentagrophytes to terbinafine and T. violaceum to griseofulvin, stressing the critical role of routine susceptibility profiling. The findings highlight the growing challenge of antifungal resistance in dermatophytes and the importance of optimizing diagnostic and treatment strategies to improve patient outcomes.

Introduction: Intracranial hemorrhage, most often intraparenchymal hemorrhage, is an increasingly common and fatal complication of warfarin-induced coagulopathy. Warfarin remains the anticoagulant of choice in valvular atrial fibrillation. However, warfarin has a narrow therapeutic index. Extra axial hemorrhage due to warfarin-induced coagulopathy is a rare adverse event. We present a rare case of right vestibulocochlear and lower motor neuron (LMN) facial palsy secondary to an intracranial bleed along the cerebellopontine angle.

Case description: A 36-year-old woman presented with headache, giddiness, sudden onset of right-sided hearing loss, and left-sided deviation of the angle of the mouth. Symptoms had developed acutely over 4 hours. She was diagnosed with mitral stenosis at 8 years of age and had undergone mitral valve repair 2 years before presentation, after which she was started on warfarin. She was lost to follow-up for over a year and on presentation had right-sided sensorineural hearing loss along with features such as difficulty raising her right eyebrow, inability to close her right eye, and water drooling from the right side, all consistent with a right LMN facial palsy and vestibulocochlear nerve palsy. MRI brain showed an extra-axial hemorrhage at the right cerebellopontine angle cisterns.

Conclusion: Warfarin-induced intracranial bleeds without involving the parenchyma are a rare event, and through this case, we would like to highlight the importance of timely monitoring of the international normalized ratio (INR) of patients on warfarin therapy.

Background: Dyslipidemia is one of the driving forces in the pathogenesis of atherosclerosis and its resultant cardiovascular disease. Both these conditions are characterized by an increase in proatherogenic lipids compared to anti-atherogenic lipids. Atherogenic Indices have been developed to predict CVD risk without increasing the cost of testing; however, most of the studies done to date have used these indices in patients who have already suffered a coronary event. Dyslipidemia is most prevalent in cases of type 2 diabetes mellitus (T2DM). Therefore, this study was designed to assess atherogenic risk (via atherogenic indices) in newly diagnosed treatment-naïve obese and lean patients of T2DM.

Materials and methods: Treatment-naïve, newly diagnosed patients of T2DM were recruited and grouped into obese (BMI ≥ 25 kg/m²) and lean (BMI <18.5 kg/m²) groups. Blood was collected in a fasting state for the estimation of glycemic parameters and fasting lipid profile. Atherogenic indices (LDL-C/HDL-C, non-HDL-C, TC/HDL-C, atherogenic coefficient, lipoprotein combined index, and atherogenic index of plasma (AIP)) were calculated using predefined formulas.

Results: LDL-C/HDL-C, non-HDL-C, TC/HDL-C, atherogenic coefficient, lipoprotein combined index, and AIP were higher in the obese group compared to the lean group. However, these calculated indices were above the recommended cutoffs in both obese and lean patients with T2DM.

Conclusion: This study is the first to document increased atherogenic risk in both obese and lean patients (newly diagnosed) with T2DM. Although CVD risk is higher among the obese patients, aggressive control of plasma lipids is required in all patients with T2DM, irrespective of BMI.

We present a case of a 60-year-old male with a fever of unknown origin (FUO) who was ultimately diagnosed with perinuclear antineutrophil cytoplasmic antibodies (p-ANCA)-associated microscopic polyangiitis (MPA) and aortitis. This case underscores the diagnostic intricacies and therapeutic challenges of managing such rare and severe multisystem involvement. It also highlights the critical importance of clinician awareness for prompt recognition and effective management of similar presentations.