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

Psittacosis is a rare zoonotic disease caused by a gram-negative obligate intracellular bacterium Chlamydia psittaci, which is transmitted through contact with infected birds. It comprises approximately 1% of all community-acquired pneumonia cases. However, this can be just the tip of the iceberg pertaining to the lack of routine testing and awareness of this disease entity, thereby requiring a high index of suspicion for its diagnosis. We report a case of a 37-year-old male presenting with high-grade fever with chills, acute onset of dyspnea, dry cough, arthralgia, and myalgia which was not responding to broad-spectrum empirical antibiotics and supportive care. We started evaluating the patient as a case of pyrexia of unknown origin (PUO), but the fever workup turned out to be inconclusive. This prompted us to revisit the history. It was found that the patient owned a parrot that was sick for the last 15 days. The temporal correlation of the illness with a history of exposure made us suspect psittacosis, which was confirmed by treatment with doxycycline resulting in a drastic improvement in the patient's condition. By this, we want to highlight that history remains the time-tested guide for diagnosing and treating PUO.

We report an unusual presentation of Cytomegalovirus (CMV) cutaneous perianal ulcerative lesion in a patient with severe immunosuppression. A 43-year-old male presented with perianal ulcer along with bleeding and pain while passing stools. On biopsy, the ulcer showed typical histopathological features of CMV infection with involvement of endothelial cells. The patient was treated with oral valganciclovir for CMV ulcer which showed significant improvement subsequently. After 2 weeks, antiretroviral therapy (ART) was reinitiated with Tenofovir disoproxil fumarate, Lamivudine, and Dolutegravir. A high index of suspicion should always be maintained for CMV cutaneous ulcers in individuals with advanced immunosuppression.

Introduction: Tuberculosis (TB) represents a significant communicable disease on a global scale. The clinical manifestations of abdominal TB frequently resemble those of various gastrointestinal disorders, potentially leading to delays in accurate diagnosis. Materials and methods: From January 2012 to December 2019, consecutive patients aged 12 years and older, diagnosed with gastrointestinal TB at a tertiary care center in North India, were enrolled. Demographic and clinical data, radiological imaging findings, gastrointestinal endoscopy results, and histopathological findings were meticulously recorded. Antitubercular treatment was administered, and gastrointestinal endoscopy was performed upon the completion of treatment. Results: During the study period, 234 patients with gastrointestinal tuberculosis were enrolled, of which 151 (64.5%) were male and 83 (35.5%) were female. The most common presenting symptoms included weight loss (94.9%), abdominal pain (85.9%), fever (51.7%), and diarrhea (30.8%). The ileocecal region was the most frequently affected site (76.1%), followed by segmental colonic TB (17.1%). The most common finding on computed tomography (CT) of abdomen was thickening of the bowel wall with/without local or mesenteric lymphadenopathy. The most common endoscopic lesions were ulcerations (82.0%) followed by nodularity (73.9%), deformed cecum and ileocecal valve (41.9%) and strictures (11.1%). Histopathological examination of endoscopic biopsy revealed, well-formed granulomas in 94 (40.2%), collection of epithelioid cells with Langhans giant cells in 66 (28.2%), and chronic nonspecific inflammatory changes in 74 (31.6%). All patients responded to the antitubercular treatment. Follow-up colonoscopy in 171 (73.1%) patients showed regression of lesions. Conclusion: Gastrointestinal tuberculosis (GiTb) presents with nonspecific symptoms such as weight loss, fever, and abdominal pain, with ileocecal region being most commonly involved. Gastrointestinal endoscopy shows ulceration, nodularity, and strictures as prominent findings. Histopathology and culture were helpful for making diagnosis in almost half of the patients with GiTb. Majority of the patients responded well to antitubercular treatment.

Pulmonary embolism (PE) is an important cause of morbidity and mortalityespecially among hospitalized patients. Although the exact epidemiology of PE is not known in India, several studies have shown that it is missed and mismanaged not infrequently, leading to significant cardiovascular morbidity and mortality. Indian consensus for the diagnosis and treatment of acute PE has been previously published. Recent findings from studies including data available from Indian studies have expanded our knowledge with respect to the optimal diagnosis, assessment, and treatment of patients with PE and have been integrated into this review article. Acute PE patients should be stratified according to early mortality risk. Clinical measures, right ventricular (RV) dysfunction markers, and myocardial injury should be used to determine risk stratification. The clinical prediction criteria [pulmonary embolism severity index (PESI) and Hestia criteria] should be routinely used in emergency departments. Investigations, such as D-dimer, electrocardiogram (ECG), chest X-ray, routine labs, N-terminal pro B-type natriuretic peptide/brain natriuretic peptide (NT-ProBNP/BNP), troponin I or troponin T, heart-type fatty acid binding protein (H-FABP), echocardiography, lower limb compression ultrasonography (CUS), computed tomographic-pulmonary angiography (CTPA), ventilation-perfusion scintigraphy (V/Q scan), and pulmonary angiography should be appropriately selected in suspected cases of PE as per risk stratification. The main treatment in medical management of acute PE comprises anticoagulants and thrombolytics. According to current guidelines, oral anticoagulants such as warfarin are recommended to be started at the time of diagnosis together with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux (all grade IA). Owing to their predictable bioavailability and pharmacokinetics, novel oral anticoagulants (NOACs) can be given at fixed doses without routine laboratory monitoring. Recurrence is not uncommon on cessation of therapy, and hence long-term anticoagulation may be required in selected cases. Strong positive evidence is available for the use of thrombolytics in the management of acute PE.

A 42-year-old chronic alcoholic, nondrug addict male patient with a normal sexual and marital history was brought by relatives to the emergency department of Government Medical College, Kota. He had gradually increasing yellow discoloration of eyes and body for 7 days, progressively worsening altered sensorium for 4 days, up to the extent of not being able to recognize family members for the last 2 days. There was no history of any drug intake. On examination, vitals were in the normal range with blood pressure (BP) 130/80 mm Hg, pulse rate (PR) 80/min, peripheral oxygen saturation (SpO₂) 98% at room air, no pallor, and deep icterus was present. The patient was irritable, disoriented, semiconscious, and not responding to commands. Bilateral plantar reflex was extensor. P/A examination showed generalized distension and nontender 4 cm firm hepatomegaly.

Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused coronavirus disease 2019 (COVID-19) has been connected to numerous opportunistic bacterial and fungal infections. Mucormycosis is a fatal opportunistic disease that became much more common with the second COVID-19 wave. We plan to look into the prognosis and course of mucormycosis following COVID-19, as well as the risk of mucormycosis in cases with COVID-19 pneumonitis. Materials and methods: Just 100 verified cases of mucormycosis that were admitted to a civil hospital in Rajkot between April 2021 and March 2022 were included in this retrospective cross-sectional investigation. Data gathered from medical records included diagnoses, vital signs, test findings, microbiological information, usage of antibiotics, and outcomes. After entering the data into Microsoft Excel, we performed analysis and computations to determine frequency, percentage, and the Chi-squared test for variable comparison. Results: About 77.0% of the 100 mucormycosis patients were between the ages of 41 and 70. The bulk of them were male. The most frequent associated comorbidity was diabetes mellitus (DM) (30.0%). The most commonly impacted sinuses were the maxillary and ethmoidal ones. Amphotericin B was administered intravenously to each patient. In total, 82.0% of patients survived while 18.0% of patients died. Conclusion: Mucormycosis is an extremely rare, serious, and sometimes fatal infection. Because of comorbidities like diabetes and smoking, it went up with COVID-19. The use of glucocorticoids during COVID-19 treatment was the main risk factor.

In a patient presenting with forgetfulness, history taking comprises asking questions pertaining to specific cognitive domains namely memory, language, executive function, visuospatial functions, and social cognition to characterize the clinical phenotype. The next step is to administer a standardized screening test for cognitive assessment, namely the Montreal Cognitive Assessment (MoCA)/mini mental status examination (MMSE). These have been validated in five Indian languages. Detailed lobar function tests to assess functions of frontal, temporal, parietal, and occipital lobes namely planning, set-shifting, recent and remote memory, apraxia, agnosia, cortical sensory loss, language, etc., are the final step to identify the possible subtype of dementia. Attention testing with random letter cancellation test must be performed at the outset, as an inattentive patient cannot complete rest of the examination. Clock drawing is a simple bedside test that can assess global cognitive functions by detecting deficits in attention, planning, right-left orientation, constructional ability, visuospatial orientation, and neglect.

Larsen's syndrome is an exceedingly rare and debilitating skeletal disorder characterized by multiple bony deformities and joint contractures. A 47-year-old female grappled with its severe manifestations, including functional quadriplegia, limb atrophy, and various orthopedic surgeries. This is the only reported case of the concurrent presence of antiphospholipid antibody syndrome (APLA) and Larsen's syndrome. While Larsen's syndrome's genetic underpinnings are known to involve filamin B (FLNB) gene mutations, this patient's distinct presentation and complex clinical history added layers of intrigue. Intriguingly, APLA predisposes individuals to thrombotic events, but the patient's manifestation with rectal bleeding with normal coagulation parameters introduced an unexpected twist. Despite the absence of clear causative links, this case highlights the rarity of encountering Larsen's syndrome and APLA concurrently. Their potential interactions and mutual influence remain largely unexplored, underscoring the need for more research in this domain. Intricacies also emerged in the management of APLA within a surgical context. The decision to transition between anticoagulants underscores the necessity of individualized and comprehensive care for patients grappling with multiple comorbidities. It raises questions about the potential overlap between Larsen's syndrome and connective tissue diseases, like Marfan's syndrome, that warrant further exploration. The case also emphasizes the significance of increased patient mobilization to prevent thrombotic events in those who are bedridden or wheelchair-bound. This extremely unique presentation, featuring a genetic skeletal disorder, an autoimmune condition, recurrent diaphragmatic hernias, and a colon polyp-induced hemorrhage, beckons further research and analysis to unravel any potential associations between these conditions.

Background: Following the outbreak of coronavirus in Wuhan, China in 2019, there has been multiple waves of different variants of COVID-19 throughout the world in the continuum of a pandemic. This study aims to compare different clinical and laboratory parameters of hospitalized patients in Omicron-driven 3rd wave vs Delta-driven 2nd wave in India. Materials and methods: This was a retrospective cross-sectional observational study that was done in the Department of General Medicine, Mahatma Gandhi Hospital, Dr S N Medical College, Jodhpur (Rajasthan). It included 100 patients of 3rd wave and 2nd wave respectively who were hospitalized. The primary outcome of the study was patient's survival and condition at discharge and secondary outcomes included length of hospital stay and mode of oxygenation. Results: The presence of cough, shortness of breath, and loss of taste are more common symptoms in 2nd wave vs 3rd wave with p-value being 0.0002, 0.004, and < 0.0001 respectively. The severity of illness, need for intensive care unit (ICU), and outcome in terms of discharge with oxygen or without oxygen were also statistically significant in the 2nd wave vs 3rd wave with p-value being < 0.0001 for all three variables. A total of 67% of patients were vaccinated in 3rd wave group compared to 11% in 2nd wave group (p-value < 0.0001). Comparison of laboratory parameters also revealed statistically significant results with D-dimer, quantitative C-reactive protein (CRP), normal (NL) ratio, and serum lactate being more deranged in the 2nd wave compared to the 3rd wave with p-value being < 0.05. Comparison of involvement of lung parenchyma based on computed tomography (CT) severity score revealed p-value < 0.0001 that is statistically relevant. Conclusion: Omicron-driven 3rd wave was associated with significantly less severity, less inflammatory response, and better outcome compared to Delta-driven 2nd wave. More vaccination and probably less intrinsic virulence during 3rd wave has a major role in the better outcome.

Balancing the risks of ischemic and bleeding events in patients who have undergone coronary angioplasty with drug-eluting stents (DES) is a delicate task. Individuals recovering from myocardial infarction are at increased risk of recurrent ischemic events, highlighting the potential benefits of rigorous secondary prevention measures.¹ Dual antiplatelet therapy (DAPT), combining aspirin with P2Y12 inhibitors such as clopidogrel or ticagrelor, forms the cornerstone of post-percutaneous coronary intervention (PCI) care aimed at preventing stent thrombosis and lowering the risk of ischemic events. Current medical guidelines recommend a 6-month duration of DAPT for stable coronary disease and 12 months for acute coronary syndrome (ACS).