APICON - 2002

Free Papers - Session

Platform Presentation

14th January 2002, Monday

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1200 - 1330 hrs.
Hall B : Cardiology

 

1.

Role of Single-Stop "Magnetic Resonance Coronary Angiography" and "Gated Helical-CT Coronary Calcium Scanning" for Diagnostic Workup of Chest Pain Syndromes

 

DR Jangid, N Trehan - Escorts Heart Institute and Research Centre, New Delhi - 110 025, India.

 

Introduction : In the domain of non-invasive diagnostic armamentaria uncertainties continue to linger in the assessment of chest pain syndromes. Conventional TNT suffers from low sensitivity and specificity for diagnostic work-up for coronary artery disease (CAD). Stress myocardial perfusion scintigraphy (SMPS) and stress echocardiography detects only haemodynamically significant coronary artery lesions ("stable-angina") and `Electron Beam-CT’ / `ECG-Gated Spiral-CT’ detects coronary calcium even in non-stenotic atherosclerotic plaques ("unstable angina").

Methods : We studied 32 patients using multiple modalities to assess the clinical diagnostic role of a single-stop "Magnetic resonance coronary angiography (MRCA)" and "Gated helical - CT coronary calcium scanning (ghCT-CCS)".

Results : Positive `99mTc-Tetrofosmin SMPS’ signifying haemodynamically significant CAD was present in 25 (78%) patients.

S. No.

Modality

% sensitivity

1.

TMT

63%

2.

99mTc-SMPS

78%

3.

ghCT-CCS

82%

4.

MRCA

71%

 

Conclusions : ghCT-CCS was most sensitive (82%) for detection of and for objective evidence for angina pectoris, while TMT was least sensitive (63%). `99mTc-Tet-SMPS’ > MRCA had intermediate sensitivities. In the increasing order of sensitivities the modalities were (TMT:63%) (MRCA:71%) (99mTc-SMPS:78%) (ghCT-CCS:82%) (ghCT-CCS+MRCA:92%) (ghCT-CCS+99mTc-SMPS:93%).

   

2.

A Study of Ischemic Preconditioning Using Dynamic Stress Test and Potassium Channel Opener

 

D Srivasavi, KR Sethuraman, K Anil Kumar, DKS Subrahmanyam - JIPMER, Pondicherry - 6.

 

Aims and Objectives : The aim of this study was to document whether ischemic preconditioning occurs in patients with coronary artery disease by treadmill test and potassium channel opener, nicorandil.

Materials and Methods : The study was conducted in JIPMER 1999-2001 in 35 patients with stable angina and a positive TMT, in two phases. In the Phase I, a second TMT was performed after four hours of the initial TMT using Bruce protocol on Day 1. In phase II, a third TMT was repeated on Day 4 after six doses of 20 mg nicorandil.

Results : In phase I, the exercise duration, time for 1 mm and max. ST depression, metabolic equivalents, rate pressure product at 1 mm and max. ST depression increased significantly while the intensity of anginal pain decreased.

In phase II, similar trends were observed except in the time for 1 mm and max. ST. Additional benefits being a more effective reduction of anginal pain, increase in METs and exercise duration and also a decrease in time for recovery.

Conclusions : Ischemic preconditioning occurs in patients with coronary artery disease and the benefit accrued by nicorandil may be equivalent to that by exercise.

   

3.

Admission Electrocardiogram - A Predictor of Mortality in Acute Myocardial Infarction

 

DP Singh, K Sinha, AK Shrivastava, S Shukla - SS Hospital Institute of Medical Sciences, BHU, Varanasi.

 

This study was carried out in casualty department of Institute of Medical Sciences, BHU, Varanasi. Patients of Acute MI attending the casualty service of the hospital were studied.

Several ECG indicators of mortality in acute mycardial infarction (AMI) have been described. Three indicators in the admission ECG were correlated with early mortality (< 72 hours) in AMI. The ECG pedictors of mortality that were studied were 1) J point elevation > 50% of the amplitude of the `R’ wave in leads with ST elevation, 2) QRS slur and, 3) reciprocal changes of ST segment.

Out of 225 cases of acute MI 70 were eliminated because they had inverted T wave at the admission ECG. The prevalence of the ECG predictors of mortality were :

1. J point elevation > 50% of the amplitude of the R wave in leads with ST segment elevation (n=121; sensitivity correlation with mortality 100%, specificity = 7.5%).

2. QRS slur (n=55; sensitivity = 86%, specificity = 56.2%) and

3. Reciprocal changes of the ST segment (n=191; sensitivity = 72.4%, specificity = 26.1%).

The most sensitive predictor was J point elevation but its specificity was low. If all the three predictors occurred together it was most specific (76.33%). Early coronary intervention may be indicated in patients with all three predictors.

   

4.

Antioxidant and Free Radical Activity in Cardiac Ischaemic and Reperfusion Injury

 

CK Meena, Sangeeta Meena, MR Kumhar, S Meratwal, K Yadav - JLN Medical College, Ajmer, Rajasthan.

 

The study was conducted on 100 patients of acute myocardial infarction (AMI) to find out antioxidant by superoxide dismutase (SOD) and free radical by malondialdehyde (MDA) activity during ischaemic and reperfusion injury. Group A - comprising 50 patients of AMI who were treated with conventional treatment. Group B - 50 patients of AMI who were treated with streptokinase (SK) therapy and Group C - healthy controls. SOD and MDA levels were measured at admission in both study group and at 30 minutes, three hours and 12 hours after SK therapy in group B patients; Mean ± SD, range and % decrease and increase in the level of SOD and MDA are shown in Table 1.

We concluded that SOD activity is significantly decreased and MDA activity significantly increased in AMI which occurs still greater following reperfusion injury (P < 0.001).

Table  1 : SOD and MDA activities in different groups

 

SOD

MDA

Group

Mean

SD

Range decreased

%

Mean

SD

Range increased

%

Group C

0.714

± 0.084

0.56-0.80

-

6.86

± 0.818

5.6-8

-

Group A

0.364

± 0.35

0.30-0.42

49

7.26

± 4.37

6-9

5.83

Group B

 

 

 

 

 

 

 

 

Before

0.382

± 0.047

0.30-0.50

46

6.28

± 4.58

6.5-9.0

8.45

SK

 

 

 

 

 

 

 

 

30 min

0.276

± 0.045

± 0.22-0.38

61

10.6

± 5.03

9-14

54

3 hrs

0.30

± 0.045

0.28-0.38

58

7.86

± 3.45

7-10

13

12 hrs

0.318

± 0.45

0.56-0.40

56

9.64

± 6.00

6.5-9

41

   

5.

Effect of Cardioprotective Drugs on Clinical Profile of Acute Myocardial Infarction

 

RS Khot, MM Paithankar, RG Salkar - Department of Medicine, Government Medical College, Nagpur.

 

Introduction : The role of cardioprotective drugs like b-blockers, Ca channel blockers in secondary prevention of acute myocardial infarction (AMI) is well proved. But what is the effect of these drugs on the clinical profile of acute myocardial infarction, if it does occur?

Aims and Objectives : To study the effect of prior therapy with various cardioprotective drugs like b-blockers, Ca channel blockers, ACE inhibitors etc. on the clinical profile, complications and mortality in acute myocardial infarction.

Material and Methods : This was a retrospective observational comparative study in which 125 consecutive patients of acute myocardial infarction admitted to the ICCU of Government Medical College were included. Patients were divided into two groups : Group A (n=84) who did not receive any cardioprotective drug, Group B (n=41) who were taking cardioprotective drug for reason other than CAD, were compliant and admitted for the first time with AMI. Patients with established CAD were excluded. Detailed history, relevant investigations including a predischarge 2-D ECHO were done and patients were followed till discharge or death. Statistical analysis done using Chi-square test on MINITAB MTLR.

Observations : Mean age of patients was 56.84 ± 11.2 and 53.68 ± 10.64 and M:F ratio was 3.4:1 and 2.1:1 in group A and group B respectively. Forty one patients were using cardioprotective drugs. b - blockers (14.3%), ACE inhibitors (24.4%) Ca channel blockers (19.5%), aspirin (14.6%) and others (4.87%), for causes like hypertension (68.29%), diabetes (17.1%), mitral valve prolapse (4.9%), thyrotoxicosis (2.4%), others (7.3%). Mean duration of drug use was 3.14 ± 1.9 years. Typical anginal chest pain was more common in group A whereas chest pain was atypical in group B. Extensive, anterior wall MI (24.4%) was significantly less common in group B. Complications : Cardiogenic shock (4.87%), heart blocks (4.9%), arrhythmias (4.87%) were less common in group B. Thrombolytic therapy was equally received by both groups. Mortality was less in group B i.e. 14.6% as compared to group A i.e. 22.6%. Mean duration of hospital stay was less in group B i.e. 6.5 ± 3.5 than group A 8.1 ± 6.1. Doppler and 2-D echocardiographic studies also revealed a significantly more ejection fraction (64 ± 6.4), no diastolic dysfunction and less regional wall motion abnormalities (80%) as compared to EF=58 ± 8.2, diastolic dysfunction in 4.8% and RWMA in 92.3% of group A patients.

Conclusions : In compliant patients taking cardioprotective drugs myocardial infarction presents more commonly with atypical chest pain but complications like cardiogenic shock, heart blocks and arrhythmias (VPCs) are significantly less. Mortality is also low. Ejection fraction is high and RWMA are less.

   

6.

Rescue Thrombolysis in acute Myocardial Infarction

 

S Venkatesan, D Prabhakar, G Gnanavelu, V Chockalingam - Madras Medical College, Chennai.

 

Failed thrombolysis in acute myocardial infarction occurs in 30-40% of patients. The incidence of progressive pathological remodelling and cardiac failure is high in these patients. The approach to the patient with failed thrombolysis is generally considered to be catheter based and the outcome is not clear. Bleeding can be troublesome in patients, taken for interventional procedures in the immediate post thrombolytic state. The option of repeat thrombolysis has not been studied widely and is not popular among cardiologists.

We present our experience with six patients (Age 42-56, M-6, F-0) who were thrombolysed for failed first thrombolysis. All had anterior MI and had received either urokinse or streptokinase (between four to nine hours) after the onset of chest pain. All of them had persistent ST elevation, angina not responsive to maximal doses of IV NTG and beta blockers. The initial thrombolysis was deemed to have failed. Repeat thrombolysis with streptokinase (15 lakhs) was given between 16 and 24 th hour. The clinical outcome following the second thrombolysis was rewarding. It relieved the angina, ST segment elevation came down by 50% and coronary angiogram done at 2-4 weeks showed complete IRA patency in four out of six patients. The factors responsible for failed thrombolysis is complex and multifactorial. A logical explanation from the fundamentals of clinical pharmacology would suggest that a common cause of failure of any drug is due to a inadequate first dose.

We conclude that repeat (Rescue) thrombolysis can be an effective medical intervention for failed thrombolysis in AMI.

   

7.

Lipid Peroxidation Level Before and After Thrombolytic Therapy in Acute Myocardial Infarction

 

G Ray, PK Das, R Mohanty, JM Nayak, M Panda - SCB Medical College, Cuttack, Orissa.

 

The above study included 32 cases of acute myocardial infarction who underwent thrombolytic therapy. Twenty four cases had successful therapy and three had unsuccessful therapy. The lipid peroxidation value was determined by measuring serum malondialdehyde according to the procedure of Satho et al, 1978. The pretreatment lipid peroxidation value in the 24 cases was 5.81 ± 1.35 n mol/ml and the post-treatment value was 7.35 ± 1.82 n mol/ml, indicating significantly higher value after successful thrombolysis (P < 0.001). The peroxidation value before and after thrombolysis in unsuccessful eight cases were 5.24 ± 0.95 n mol/ml and 5.13 ± 0.96 n mol/ml respectively indicating no statistical difference.

Out of 24 cases of successful thrombolysis nine had complications. The post-treatment lipid peroxidation values in complicated and uncomplicated cases were 8.1 ± 1.5.8 n mol/ml and 6.6 ± 1.62 n mol/ml respectively showing significantly higher result in complicated cases. (P < 0.001).

Therefore, it was concluded that lipid peroxidation after successful thrombolysis of acute MI is increased due to overproduction of free radicals. These free radicals might be causing damage to the myocardium leading various post-thrombolytics complications.

   

8.

Study of CRP as an Indicator of Prognosis in AMI

 

P Mishra, RN Dwivedi, RPS Bharadwaj, Mohd. Ahmad, A Lalchandani, A Puri, S Mittal, K Singh - KPS, PG Department of Medicine,GSVM Medical College, Kanpur.

 

AMI (acute myocardial infarction) is associated with rise in serum levels of markers of acute inflammation like C-reactive protein. CRP is an indicator of underlying coronary inflammation as well as of the extent of myocardial necrosis. We aimed to study the serum concentrations of C-reactive protein in patients of AMI and their subsequent in-hospital prognosis.

Material and Methods : The present study was done on 50 cases of AMI presenting without any complication. Twenty five cases of chest pain which were not due to myocardial infarction, acted as controls. All the non-cardiac causes of rise in serum CRP were ruled out both in cases as well as controls. Serum CRP concentrations on admission were noted. All the cases and controls were followed for any complication like LV dysfunction, post-MI angina, arrhythmias etc. during their hospital stay.

Observation : Serum CRP was increased (> 6 mg/l) in 62% patients on admission. The complication like arrhythmias, post MI angina, hypotension etc. were present in 71% of patients with increased CRP response on admission. Complications were observed in 25% of patients with normal CRP response on admission (p < 0.05). Left ventricular dysfunction was observed in 77.4% patients with increased CRP response on admission. 57% patients with normal CRP response (< 6 mg/l) also had evidence of left ventricular dysfunction.

Conclusion : Thus serum CRP concentration on admission in patients of AMI is significant prognostic indicator of their in-hospital stay.

   

9.

Clinical Profile of Acute Myocardial Infarction (Q Wave and Non-Q Wave) in Young Patients 1 Year Study

 

BS Kushwaha, SB Mathur, S Dwivedi - UCMS and GTB Hospital, Delhi.

 

The incidence of acute myocardial infarction (AMI) in young age has shown steadily rising trend in last few decades. The diagnostic significance of Q wave MI has an important diagnostic, therapeutic and prognostic implications. Therefore it was decided to study the profile of Q and non-Q wave MI in young patients. We studied 92 patients below the age of 40 years (86 males and six females) of AMI admitted in our hospital in the year 1999-2000. Diagnosis of MI was based on clinical, ECG and cardiac enzyme study. In total 48 (52%) had anterior wall MI, 40 (43%), inferior wall MI (32 inferior and lateral wall and eight right ventricular MI) and only 4 (5%) had non-Q wave MI. Fifty six (60%) patients got admitted within 12 hours of onset of symptoms and out of it 48 (86%) were thrombolysed. Eight patients (8.6%) had complications including arrhythmia and cardiogenic shock. Echocardiographic evaluation was carried out in 39 (42%) patients, out of which 25 (64%) had LVEF less than 40% and had regional wall motion abnormalities.

Risk factor evaluation revealed (8 (8.6%) had positive family history, 60 (65%) were smokers, 6 (6.5%) obese, 24 (26%) alcoholic, 8 (8.6%) diabetic, 40 (48%) hypertensive and 52 (56%) dyslipidemic. Seven patients (7.6%) who died had ant wall MI. Our data indicate that Q wave MI constitute a major subgroup in young patients below the age of 40 years and had frequent association of preventable risk factors like smoking, hypertension while non-Q wave MI less common showed fewer complications and mortality.

   

1200 - 1330 hrs.
Hall C : Diabetes

   

10.

Plasma Fibrinogen in Type 2 Diabetes Mellitus

 

V Dedeepiya Devaprasad, SK Rajan, MA Elangovan - Government Stanley Medical College Hospital, Chennai - 1.

 

Objective : To estimate the plasma fibrinogen levels in patients with type 2 diabetes mellitus and to find out its association with diabetic complications and insulin therapy.

Material and Methods : Ninety patients of type 2 diabetes mellitus (DM), 60 on OHA and 30 on insulin were selected. After screening for complications the diabetics were separated in two groups. Group I had at least one of the three complications coronary artery disease - CAD (ECG changes), nephropathy (albuminuria) and hypertension (HT). Fourty five age and sex matched controls were selected. Plasma fibrinogen levels were assessed in all of them by the colorimetric method.

Results : Patients with type 2 DM were found to have elevated levels of plasma fibrinogen (450 mg/dl to 980 mg/dl) when compared to the normal value (286 ± 67 mg/dl) obtained in controls. Patients with longer duration (11-15 years) had a significantly raised plasma fibrinogen levels (807 ± 162 mg/dl) than shorter duration < 5 years (617 ± 137 mg%).

Plasma fibrinogen levels were higher in hypertensive patients (831 ± 107 mg/dl, 41 pts.) than in normotensives (599 ± 113 mg/dl, 49 pts.).

Plasma fibrinogen levels were high in patients on insulin (885 ± 85 mg/dl, 30 pts.) compared to those on OHA (658 ± 160 mg/dl, 60 pts.).

Plasma fibrinogen levels were high in patients with ECG changes (877 ± 77 mg/dl, 21 pts.) than in those without ECG changes (663 ± 154 mg/dl, 69 pts.).

Plasma fibrinogen levels were high in patients with proteinuria (867 ± 167 mg/dl, 21 pts.) than in those without proteinuria (599 ± 113 mg/dl, 69 pts.)

Conclusions :

1. Plasma firbrinogen was raised more in type 2 diabetics especially those with longer duration disease (11-15 years).

2. Insulin therapy in diabetics causes greater fibrinogen levels.

3. Plasma fibrinogen was raised more in type 2 diabetics with complications evidenced by ECG changes, proteinuria, HT. It probably can be used as a marker to predict the occurrence of complications.

   

11.

1H NMR Spectroscopy of Soleus Muscle in Non-Obese Healthy and Type 2 Diabetic Males in Northern India : High Intramyocellular Lipid Content Correlates with Higher Percent Body Fat and Abdominal Obesity

 

S Sinha*, A Misra*, NR Jagannathan**, RM Pandey***, M Kumar**, NK Vikram*, J Rama - Department of *Medicine, **Nuclear Magnetic Resonance, ***Biostatistics, All India Institute of Medical Sciences, New Delhi - 110 029, India.

 

Intramyocellular lipids (IMCL) appear to be important in the pathogenesis of insulin resistance. This study was performed to estimate IMCL in the soleus muscle of non-obese healthy and type 2 diabetic subjects and correlated to the anthropometric parameters, fasting blood glucose, plasma lipids, and insulin sensitivity in Asian Indians from North India. Twenty males (10 each, type 2 diabetes mellitus and healthy controls) with body mass index (BMI) < 25 mg/m2 were subjected to body composition analysis, blood glucose and insulin levels, and Proton Nuclear Magnetic Resonance Spectroscopy of soleus muscle. Approximately twice higher IMCL content was observed in type 2 diabetic patients as compared to healthy males (p < 0.05). IMCL content of healthy subjects with % body fat (BF) > 25%, and IMCL content of healthy and diabetic subjects with waist-hip ratio (WHR) > 0.95 were higher than subjects < 25% BF and WHR < 0.95 respectively, however, it was significant only in healthy subjects (p < 0.05). IMCL content of soleus muscle correlated significantly with waist circumference (r=0.71, p < 0.05), and WHR (r=0.73, p < 0.05), in healthy males but not in diabetic males. In both groups, however, IMCL did not correlate to insulin sensitivity (HOMA).

Deposition of IMCL in soleus muscle is closely associated with excess body fat and abdominal obesity in healthy Asian Indian men even when they are non-obese (according to BMI), however, its lack of relationship with insulin sensitivity needs further studies.

   

12.

Insulin Resistance and Clustering of Atherogenic Risk Factors in Women Belonging to Lower Socio-Economic Strata in Urban Slum of Northern India

 

NK Vikram*, A Misra*, D Chaudhary*, V Mittal*, J Rama Devi*, RM Pandey**, N Khanna***, R Sharma***, S Peshin**** - Department of *Medicine, **Biostatistics, ***Dietetics; ****Pharmacology, All India Institute of Medical Sciences, New Delhi.

 

Background and Aim : Recent studies of people belonging to low socio-economic strata settled in urban slums indicate significantly adverse risk factor profile. Aim of the present study was to study the prevalence of hyperinsulinemia, insulin resistance and other atherogenic risk factors in women living in urban slums of northern India.

Methods : Healthy asymptomatic female subjects (n=80) from an urban slum were evaluated clinically [anthropometry including body mass index (BMI), waist-hip ratio (WHR) and percentage body fat (% BF)] and fasting venous blood samples were obtained for biochemical investigations (blood glucose, lipid profile and insulin levels). Insulin sensitivity was assessed by HOMA index. Atherogenic risk factors studied were hypertension, hypercholesterolemia (> 200 mg%), hypertriglyceridemia (> 200 mg%), low high-density lipoprotein cholesterol (HDL-c, < 35 mg%) and high low-density lipoprotin cholesterol (LDL-c, > 160 mg%).

Results : High prevalence of obesity (37.5%), hypertension (40.7%), hypercholesterolemia (35%), hypertriglyceridemia (26.6%) and high LDL-c (29%) was observed. Subjects were stratified into tertiles according to HOMA values : tertile 1 (1-2, 23.7%), tertile 2 (> 2-4, 53.8%) and tertile 3 (> 4, 22.5%).

Conclusion : High prevalence of insulin resistance and components of IRS in women living in urban slum poses higher risk of development of atherosclerosis and its complications in them.

   

13.

Plasma Level of Tumour Necrosis Factor-a in Type-2 Diabetes Mellitus and Its Correlation with Glycemic Control

 

J Sarangi, US Mishra - MKCG Medical College, Berhampur - 760 004, Orissa.

 

Objectives : There is a significant increase in cardiovascular risk among patients with type-2 diabetes mellitus. Estimation of serum levels of tumour necrosis factor - a (TNF a) might help to identify patients at high risk. The cytokine TNF-a is variously implicated in diabetes. It is said to cause b-cell damage leading to type-1 diabetes mellitus. It also influences the formation of atherosclerotic vascular lesions. But its role in type 2 DM is not documented. We carried out this study in a tertiary care centre to find out the levels of TNF-a in type 2 diabetes mellitus and the possible association of this cytokine with glycemic control.

Design and Subjects : One hundred and four outpatients (78 male, 26 female) with established type 2 diabetes mellitus of mean duration 12.4 ± 4.6 years and 50 age and sex matched healthy controls were the subjects of our study. None of our study participants suffered from inflammatory or other concurrent diseases. TNF-a was estimated by using ELISA in the study group and among the healthy controls. Glycosylated hemoglobin (HbA1c) was estimated in the study as well as control group. Relationship between variables were evaluated by non-parametric correlation coefficients.

Results : TNF-a plasma levels was significantly higher in type-2 diabetes patients (24.6 ± 8.4 pg/ml) than in non-diabetic healthy controls (9.6 ± 4.3 pg/ml) with P value < 0.001.

There is a positive correlation between plasma TNF-a with HbA1c (r=0.58, P < 0.01).

Conclusion : Our outcome measures indicate that, in type 2 diabetes mellitus plasma TNF-a levels are increased and reveal significant correlation with long term glycemic control parameter HbA1c.

   

14.

Utility of Ankle-Brachial Index by Doppler Ultrasonic Technique in Diabetes Mellitus

 

SD Zawar, CM Atkar, DV Doifode - Department of Medicine, Indira Gandhi Medical College, Nagpur.

 

To find out utility of ankle-brachial index in diabetes mellitus (DM), 90 patients (29 M, 61 F) were studied. Each patient underwent complete clinical evaluation. Ankle-brachial index was estimated in each patient by Doppler and they were grouped into three groups, those with ABI ≥ 1 (29), 0.99 to 0.90 (49) and < 0.90 (12). Nephropathy, retinopathy, neuropathy, coronary artery disease, hypertension was found in 64.44, 37.77, 44.44, 37.77, 55.55 percent, respectively. The prevalence of nephropathy, retinopathy, neuropathy, CAD, PVD, hypertension in patients with ABI ≥1, 0.99 to 0.90, < 0.90 was 18 (62.06%), 6 (20.68%), 10 (34.48%), 5 (17.24%), 0, 9 (31.03%); 28 (57.14%), 17 (34.69%), 19 (38.77%), 20 (40.81%), 7 (14.28%), 32 (65.30%); 12 (100%), 11 (19.66%), 11 (91.66%), 9 (75%), 11 (91.66%), 9 (75%), respectively. Statistically significant assocaition was found between nephropathy, retinopathy, neuropathy, CAD, PVD, hypertension and ABI in the present study (p < 0.05). Statistically significant correlation was also found between age of patients, duration of diabetes, glycaemic control and ABI in the present study (p < 0.05). Majority of patients with clinical evidence of PVD i.e. 12 were having ABI < 0.90.

The present study demonstrates high prevalence of vascular complictions of diabetes in patients with ABI < 0.90 as compared to ABI ≥ 1 and ABI 0.99 to 0.90. So ABI by Doppler is a reliable indicator for assessment of severity of vascular complications of DM and ABI < 0.90 is a reliable criteria for diagnosis of PVD. So it is recommended that ABI by Doppler being a non-invasive and convenient method should be assessed periodically in patients of diabetes mellitus for assessment of micro- and macrovascular complications of diabetes mellitus.

   

15.

Carotid Intima-Media Thickness in Indian Type 2 Diabetic Subjects with Diabetic Foot

 

SS Thazhath, SK Singh, N Agarwal, VS Reddy, AG Unnikrisnan, R Kumar - Institute of Medical Sciences, BHU, Varanasi.

 

Objective : To examine the association of carotid intimal-medial thickening with peripheral vascular disease in Indian type 2 diabetic patients with diabetic foot.

Research Design and Methods : Carotid intima-media thickness (IMT) of 24 type 2 diabetic subjects with neuro-ischemic diabetic foot ulcer, were measured with the help of ultrasonographic scanning using an echotomographic system and were compared with age matched controls without significant peripheral vascular involvement of the feet.

Results : The mean age of the patients was 55 ± 7.9 years and that of controls was 51 ± 6.5 years. The mean duration of diabetes was 7.06 ± 7.14 years and 4.73 ± 3.37 years in cases and controls respectively. The mean of the carotid IMT was 1.27 ± 0.6 mm in the patients and 0.84 ± 0.05 mm in the controls.

Conclusion : Patients with type 2 diabetes and foot ulcer have marked increase in carotid IMT. This reflects generalised atherosclerosis and that IMT could be considered as a marker for vascular lesion of foot in diabetes.

   

16.

Regional Differences Concerning Diabetic Foot Lesion Outcomes - Preliminary Results of a Prospective Study

 

V Viswanathan*, S Morbach*, ZG Abbas**, R Seena***, A Ramachandran*** - *Soest, Germany; **Dar es Salaam, Tanzania; ***Diabetes Research Centre, Chennai, India.

 

Aim : To determine differences of diabetic foot lesion outcomes in different regions of the world.

Patients and Methods : Six hundred thirteen consecutive patients with diabetic foot lesions from thee centres (A = Soest/Germany, B = Dar es Salaam/Tanzania and C = Chennai/India) were included in this study. Outcome related data (healing without amputation, performed amputation, or death before healing), and data on event duration were collected. The impact of peripheral vascular disease (PVD) on outcome was investigated.

Results : PVD was evident among 50% of the patients from A, 29% from B, and 17% from C. Revascularization was implemented in 14% of the German patients, but not in centres B and C. In all three centres, healing without amputation was attainable in more than two-thirds of the lesion. Amputation had to be performed to 20.2%, 22.5% and 22.7% of the cases, respectively. Average healing duration was 92.2, 130.9 and 118.3 days, respectively. Only 7.9% of patients without PVD from centre A underwent amputation, it was far more frequent in B and C (19.0% and 18.7%, p < 0.05). Tanzanian patients with PVD had fivefold increased risk of death prior to healing compared with their counterparts without vascular disease. This explains the lower major amputation rates observed in patients with peripheral vascular disease in B (7.7%), compared to that from the other centres (A = 14.4%, C = 15.8%).

Conclusion : In the German population, the outcome of diabetic foot lesions seems to be influenced by successful therapy of PVD. Progressive infection is the primary problem among developing countries, as reflected by high amputation rates in patients without PVD.

   

17.

Infrapopliteal Angioplasties - A Non-Surgical Alternative in Limb Salvage

 

R Ravikumar*, Y Vijaya Chandra Reddy**, NG Sastry*, V Mohan* - *Madras Diabetes Research Foundation, Gopalapuram, Chennai, India; **Vijaya Heart Foundation, Chennai, India.

 

Twelve type 2 diabetic patients, seven males and five females aged 37-77 years presented with non-healing foot ulcers of at least 3-4 weeks duration. Associated atherosclerotic risk factors were hypertension - 9, dyslipidemia - 7, smoking - 7, overweight - 5.

All patients underwent angiographic evaluation. Infrarenal abdominal aortic disease was seen in four. Superficial femoral artery disease needing angioplasty was present in nine out of which four needed stenting. The details of the infrapopliteal vessels which were dilated are as follows :

Tibioperoneal trunk

-

5

Anterior tibial

-

6

Posterior tibial

-

8

Peroneal

-

6

 

Multiple lesion dilatation was done in 10 vessels.

Good angiographic results were obtained in 80% of the lesions dilated. 20% had dissection flaps with abrupt closure seen in three vessles and residual stenosis in two. Below knee amputation was done with good stump healing in four patients. Limb salvage could be achieved in the rest. Follow up ankle-brachial index showed improvement in all patients.

Conclusion : In selected type 2 diabetic patients with peripheral vascular disease, angioplasty may offer an alternative to surgery.

   

18.

A Study of Insulin Autoantibody and Free Radical Activity in Freshly Detected Diabetes Mellitus

 

N Desai, D Parikh, M Khar, R Shah, NV Yajnik, RV Dosi, NC Mehta - Baroda Medical College, Baroda.

 

Background : A comparative study of insulin autoantibody and free radical activity in freshly detected diabetes mellitus and healthy controls undertaken.

Material and Methods : We studied 30 freshly detected diabetes mellitus patients comprising 15 patients each of IDDM and NIDDM. There were eight healthy controls for NIDDM and seven for IDDM. All patients were examined in detailed and investigated with special reference to insulin autoantibody and free radical activity.

Observation : We observed that malondialdehyde - a product of lipid peroxidation was significantly raised in both IDDM and NIDDM at onset of disease while antioxidant enzymes like catalase, superoxide dismutase and reduced glutathione were significantly reduced. We found that insulin autoantibodies were only present in two patients of IDDM (13.13%).

Both were young i.e. 12 years old. Serum insulin was significantly reduced in IDDM while raised in NIDDM compared to healthy controls.

Conclusion : Thus we conclude that free radical activity at the onset of disease is significantly high in both IDDM and NIDDM and insulin autoantibodies are poor markers of autoimmune activity in IDDM subjects.

   
 

1200 - 1330 hrs.
Hall E : Gastro-Enterology

   

19.

Study of Insulin Resistance in Cirrhosis

 

SK Jain, N Sharma, R Shankar*, A Sethi, AK Gupta - Department of Medicine, LHMC and Dr. RML Hospital; *INMAS, Delhi.

 

Liver is the most important organ in the maintenance of glucose tolerance (GT). Cirrhotics have increased prevalence of DM (7-32%) and impaired GT (25-92%). Insulin resistance (IR) is an important determinant of GT. We studied IR in normal glucose tolerant cirrhotics.

Assessment of IR was carried out by insulin suppression test (Modified Harano’s method) that is simultaneous infusion of glucose @6 mg/kg/min as 20% dextrose solution and plain human insulin @50 mU/kg/hr. This method is reliable, simple to perform, inexpensive, well tolerated, sensitive and reproducible and it has excellent correlation with euglycemic clamp technique (r = 0.83). Steady state plasma glucose (SSPG) and steady state serum insulin (SSSI) of 120-150 min of infusion were determined and were used to calculate metabolic clearance rate of glucose (MCR = rate of glucose infusion / SSPG) and insulin clearance rate (ICR = rate of insulin infusion / SSSI). Lower the MCR and ICR, higher is the state of IR. Twenty cirrhosis patients (18 males and two females, 14 alcoholics and six post hepatitis B) and equal number of age, sex and BMI matched healthy controls of mean ± SD age 37.1 ± 8.3 v/s 36.5 ± 7.5 years and BMI 18.4 ± 1.8 v/s 18.5 ± 1.8 kg/m2 were enrolled after they had undergone 75 gm OGTT to exclude cases of IGT and diabetes as per NDDG (National Diabetes Data Group) criteria.

MCR glucose was found to be significantly lower in cirrhotics as compared to controls (4.96 ± 2.1 v/s 8.9 ± 1.9 ml/kg/min, p < 0.001). Also ICR was significantly lower in cirrhotics (10.73 ± 8.5 v/s 22.87 ± 13.1 ml/kg/min, p < 0.05).

Low values of MCR and ICR suggest a state of higher IR. Thus cirrhosis is a state of increased IR and this increased IR may contribute to development of impaired GT (IGT) and DM in cirrhotics later on.

   

20.

Clinical Profile of Oesophageal Carcinoma in Eastern Region Teaching Hospital of Nepal

 

JA Ansari, S Dhungel*, S Dwivedi, SP Shah**, Sudha Rani**, S Koirala - Department of Medicine, *Anatomy, **Pathology, BP Koirala Institute of Health Sciences, Dharan, Nepal.

 

Oesophageal carcinoma is remarkable for its marked geographic, ethnic and sex variation. Its high incidence is seen in a particular region of Asia called carcinoma of oesophagus belt comprising north China, Iran and Kashmir. Nepal being in the immediate neighborhood of this region and on account of very high prevalence of smoking, alcohol and betel nut consumption a high incidence of carcinoma of oesophagus is logically anticipated. However, there is not much data available regarding its clinical profile and incidence in this region. The disease is often diagnosed quite late. High index of suspicion is one of the ways for early diagnosis. In order to get some lead in this direction we planned to carry out a retrospective study of all cases of suspected oesophageal obstruction who were subjected to upper GI endoscopy between Jan. 1996 to April 2001.

A total of 3315 upper GI endoscopies were done out of which 47 (1.7%) comprising 36 males and 21 females were noted to have oesophagel mass on endoscopy. Each of them was subjected to histopathological examination. Commonest age group affected was 60-69 years (44.6%). Youngest among them was a 39 years old female while the oldest was a 90 years old lady. Out of suspected 47 cases, 44 were positive for oesophageal carcinoma. Dysphagia was the commonest presenting symptom (n=43, 91.4%), followed by weight loss (n=20, 42.5%) and vomiting (n=15, 1.9%). One had history of melaena. None had lymphadenopathy. Location-wise middle third of oesophagus was the commonest site (n=21, 9.14%), following by lower (n-18, 38.2%) and upper third (n=8, 17%). Squamous cells carcinoma was the commonest type (n=33, 75%); then was adenocarcinoma (n=6, 13.6%). Most adenocarcinoma were found near the gastroesophageal junction (five out of six). Three cases were poorly differentiated carcinoma, one each of carcinoma in situ and severe dysplasia. Our data indicate that carcinoma of oesophagus is not an uncommon malignancy in Nepal. It is common in both sexes. All middle aged patients complaining dysphagia should be subjected for upper GI endoscopy to arrive at early diagnosis.

   

21.

Clinical and Endoscopic Evaluation of Marzulene-S Granules in the Management of Gastric Mucosal Disease

 

Shweta Garg, VK Goel, KK Dwivedi, TVS Arya - LLRM Medical College, Meerut.

 

The study was undertaken in Department of Medicine, LLRM Medical College and Associated Hospital, Meerut in the year 2001 with the aim to find out the role of Marzulene-S in peptic ulcer disease and gastritis. A total of 50 patients were subjected to the endoscopic examination before and after the use of Marzulene-S in the dose of 1 sachet (Sodium azulene sulfonate-2.01 mg + L-Glutamine 663.30 mg) TDS for eight weeks. Patients were followed for two months more for symptomatic recurrence. During the treatment no other antacid, H2 antagonist or proton pump inhibitor was used. Out of 50 patients, ulcer was seen in 15 patients and gastritis in 35 patients. Number of patients showing complete healing after eight weeks were 12 (80%) and 26 (74.29%) in each group respectively while 2 (13.33%) and 6 (17.14%) patients show partial recovery and there was no improvement in 1 (6.67%) and 3 (8.57%) patients in the two groups respectively. Two (13.33%) patients in ulcer group and 3 (8.57%) patients in gastritis group show symptomatic recurrence after four months. Side effects were observed in 7 (14%) patients.

Result : Marzulene-S proved to be effective in management of gastric mucosal disease with a significantly low incidence of side effect and recurrence rate.

   

22.

Profile of Upper Gastrointestinal Bleed in a Medical College Hospital

 

D Sudhindra, YC Lakshmanakumar - Sri Devaraj Urs Medical College.

 

Aim : To analyse the aetiology and clinical profile of upper gastrointestinal bleed (UGIB) in our Medical College.

Material and Methods : All patients with UGIB who underwent upper gastrointestinal endoscopic examination between Jan. 1996 and July 2001 were included. All patients were interrogated for intake of NSAIDs, alcohol/cigarette, dyspepsia and pain in abdomen and details of UGIB. The endoscopic examination was conducted after the bleeding had been controlled. Each case was classified as varices, peptic ulcer, erosive gastritis, oesophagitis, malignancy, other diagnosis or none.

Results : Amongst 4500 UGI endoscopies conducted over 50 months, 90 patients had presented with UGI bleed, 65 (82%) were inpatients and 25 (28%) were outpatients. Endoscopy was done after the clinical condition of the patient was stabilized. The overall median age was 30 years : higher in inpatients (65) than out-patients (55 years). The overall incidence was high in males (82%), 54.4% patients had presented with hemetemesis, 32.2% with malena and 13.3% had both. Overall, peptic ulcer (31.2%), erosive mucosal disease (30%), varices (12.2%), malignancy (7.8%), fundal varices (4.4%), ankylostomiasis (8.4%) were the most frequent diagnosis and in 9% no lesion was made out. Thirty percent had h/o alcoholism, 22% had h/o taking NSAIDs, cirrhosis was seen in 16.6%, COPD in 3.3%, hepatic encephalopathy in 6.4%, hypertension in 13.3% and diabetes in 14.4%. Eleven patients amongst cirrhotics had oesophageal varices, who underwent sclerotherapy; for peptic ulcer 5.5% had local adrenaline injection, 3.3% underwent surgery for UGI bleed. Evidence of recent bleed was noted in 37% patients.

Conclusion : The three main causes of UGI bleed recognised in the present study were peptic ulcer, varices, erosive mucosal diseases which includes drug induced/antral gastritis / alcoholic gastritis / duodenitis and oesophagitis, commonest being erosive mucosal disease. Twenty percent required interventions either endoscopically or by surgery.

   

23.

A Study of Portal Gastropathy in Patients with Cirrhosis of Liver

 

Aparna Agrawal, S Chaudappa, A Sahai, A Hamide, DKS Subrahmanyam - Department of Medicine, JIPMER.

 

UGI endoscopy was done for 203 patients with cirrhosis of liver and portal hypertension. 186 (91.63%) adult patients (141 males and 45 females) were found to have congestive gastropathy on endoscopy. The details of the gastric and duodenal endoscopic changes in these patients was studied and we tried to correlate the above with the endoscopic grading of esophageal varices and H.pylori positivity. Maximum patients were in the 31-40 years (30.11%) and 41-50 years age group (27.42%). 44.09% patients had mild portal hypertensive gastropathy (PHG) and 55.91% had severe PHG changes. Of the remaining patients with unequal involvement of the fundus, body and antrum, the changes were most severe in the body of the stomach in 45.07% of these patients followed by antrum (28.17%) and the fundus (26.26%). This is contrary to the reports from Western literature. 48.93% patients had features of portal hypertensive duodenopathy (PHD)- 65.44% had mild PHD and 34.56% had severe PHD changes. Mosaic pattern (69.62%) was the commonest sign followed by cherry red spots / petechiae (36.71%), superficial reddening (30.38%), oozing/clots (23.42%), fine pink speckling (17.09%), ulcer/erosion (15.19%), and telangiectasia (8.86%) in the stomach. In the duodenum, however, patchy/diffuse congestion (73.63%) was the commonest sign followed by cherry red spots/petechiae (23.08%), ulcer/erosion (12.09%), oozing/clots (7.69%), mosaic pattern (5.5%) and telangiectasia in one patient. 5.87% patients had grade I, 16.67% patients grade II, 50.0% patients grade III and 25.80% patients had grade IV esophageal varices. Three patients had no esophageal varices. 80.11% patients had no fundal varices. 13.98% patients had grade I fundal varices and 5.91% had grade II fundal varices. H.pylori was tested in 121 patients out of which 45 (37.19%) were positive for H.pylori by the rapid urease test. Correlation of the grade of esophageal varices, fundal varices and H.pylori positivity with the severity of PHG or PHD did not reveal any statistical significance (p > 0.05) in either case.

   

24.

A Study of the Correlation Between Histomorphological Changes and H.Pylori Infection in Patients with Non-Ulcer Dyspepsia (NUD), Duodenal Ulcer (DU) and Gastric Ulcer (GU)

 

GK Sachdev, Mary Gretta*, K Uma Chaturvedi*, S Anuradha - Department of Medicine, *Patholoy, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi - 110 002.

 

Background : H.pylori has been associated with many gastrointestinal diseases - DU, GU, NUD, reflux disease and most ominously - gastric cancer. Infact, H.pylori infection has been implicated as the initiating stimulus for the development of gastric cancer by altering the mucosa. This study was carried out to evaluate the histomorphological changes in patients with DU, GU and NUD and H.pylori infection.

Methods : Eighty four patients refereed for upper gastrointestinal endoscopy for complaints of dyspepsia, not receiving any PPI’s, without prior H.pylori eradication treatment were assessed for H.pylori. H.pylori infection was confirmed if any one of the three were present. Additionally, all the biopsies were evaluated for mucosal inflammation (graded from 1+ to 3+), mucosal changes (graded from hyperplasia to dysplasia to ulceration) and assessment of gastric epithelial damage. All the above were evaluated with elaborate scoring systems. The data was statistically analysed.

Results : Of the 84 patients, 52 had NUD, 26 had DU and six had GU. The mean age (years) of the patients was 33.4, 33 and 33 in the three groups respectively. H.pylori detection rates were highest with biopsy and the detection rates for RUT, antral cytology and biopsy for the three groups was - 48%, 55%, 80.7%; 53.8%, 71.4%, 80.8% and 66.6%, 80%, 83.3% respectively. H.pylori grading, indicative of invasiveness were higher in the antral samples compared to fundal samples (p < 0.005) in NUD and DU groups. NUD group: 88.4% had evidence of gastritis and had more prominent antral involvement compared to fundal involvement. Also, H.pylori scores were higher in the antrum than the fundus (p < 0.0001) and a strong correlation was obtained between the H.pylori grades inflammatory changes and epithelial damage (p < 0.01). DU group : Similar findings of prominent inflammatory antral involvement as in the NUD group was seen. Compared to the NUD group, H.pylori showed higher invasive scores (p < 0.01). GU group. Though the GU group was small, certain trends were demonstrable. Antral predominance of both H.pylori and inflammation was evident. There was no significant correlation between H.pylori grading and intestinal metaplasia.

Conclusions : A high prevalence of H.pylori was seen in all the three groups of patients. The histomorphological changes were more prominent in antrum compared to the fundus suggesting an antral origin of H.pylori infection. A significant correlation was observed between grades of H.pylori infection and epithelial damage and it suggests that H.pylori may be the possible initiating factor in the continuum of epithelial damage, metaplasia and invasive cancer.

   

25.

Clinical and Laboratory Evaluation of Persistent Upper Gastrointestinal Symptoms in Elderly

 

A Hamide, K Sudheeran, A Agrawal - Department of Medicine, JIPMER, Pondicherry - 605 006.

 

Patients aged 60 years and above, attending Medicine OPD, JIPMER with persistent upper gastrointestinal symptoms of at least one month duration were evaluated for underlying disorders. Total 64 patients were studied with mean age 64.24 ± 4.4 with a male:female ratio of 3.5:1. Abdominal pain (91.18%), loss of appetite (37.5%), vomiting (34.35%), early satiety (31.81%), heart burn (19%), water brash (9.37%), haematemesis (6.24%), dysphagia (4.6%) and malena (4.6%) were the presenting symptoms. Epigastric tenderness (34.38%) and pallor (31.94%) were the most significant examination findings. Stool occult blood was positive in 29.03%. Upper GI endoscopy revealed oesophageal disease in 37.09%; 77.41% had gastric disease, 24.19% had duodenal disease with variable overlap. Only 4.83% had normal study. Abdominal USG showed normal study in 83.47% bilateral contracted kidneys (4.68%); bright liver 6.24%); gall stones 1.56%, liver secondaries 3.12% and hepatoma 1.56%. CT abdomen showed carcinoma head of pancreas in one case. Total 14 (21.87%) had malignant disease-two carcinoma oesophagus (14.28%), nine carcinoma stomach (64.28%), one hepatocellular carcinoma (7.14%), one liver secondaries (7.14%) and one head of pancreas (7.19%). Comparing various presentations of malignant and non-malignant disease, only presence of pallor and iron deficiency anaemia were significantly associated with malignant disease (p 0.007), odds ratio 6.38.

Our study showed that all patients above 60 years of age with persistent upper GI symptoms have to be investigated for underlying malignancy especially when they have significant anaemia.

   

26.

Prevalence of Subclinical Hepatic Encephalopathy in Cirrhotics

 

P Puri, VK Gupta, JD Mukherji, S Johri, H Singh, J Gambhir - Command Hospital (Central Command), Lucknow.

 

Background / Aims : Subclinical hepatic encephalopathy (SHE) may adversely affect daily functioning in cirrhotics. We evaluated various electrophysiological and psychometric tests for the diagnosis of subclinical hepatic encephalopathy in cirrhotics.

Methods : Forty cirrhotics (M:F = 32:8) without any overt evidence of hepatic encephalopathy were evaluated for the presence of subclinical hepatic encephalopathy. Patients with concurrent use of benzodiazepines, anti-epileptics or alcohol in the last eight weeks were excluded. All patients were evaluated with modified Child-Pugh scoring and underwent electroencephalograms (EEG). Visual evoked potentials (VEP) were done in all except in one patient due to poor compliance. Number connection test (NCT) part A was administered to all patients. However five patients could not complete the same due to illiteracy and one due to tremors. In a subsample (n=30) further psychometric analysis was done using the benton visual retention test (BVRT).

Results : The child-Pugh status was A in 12/40 (30%), B in 23/40 (57.5%) and C in 5/40 (12.5%). Any one abnormal test suggesting SHE was found in 33/40 (82.5%). The NCT was abnormal in 22/34 (64.71%). VEP showed prolonged P-100 latencies in 24/39 (61.5%). BVRT was deranged in 14/30 (46.67%). EEG was abnormal in 9/40 (22.5%).

Conclusions : There is a high prevalence of subclinical hepatic encephalopathy in cirrhotics. VEP and NCT are the best individual tests to detect SHE. However, a combination of tests picks up more cases.

   

27.

Variceal Bleed in Portal Hypertension - Is It Irksome?

 

S Usha, D Nirmala, T Rajkumar, V Jayanthi, Dwideep - Department of Gastroenterology, SMC and H, Chennai.

 

Background : The first variceal bleed in portal hypertension is associated with significant early mortality.

Aim : To determine the outcome of first and subsequent variceal bleed in portal hypertensives.

Methods : The duration of illness, details of the index and subsequent variceal bleeds, number and interval between sclerotherapy sessions in these patients were noted.

Results : There were 54 patients with cirrhosis, eight with EHPO, nine with NCPF and four with HVOTO. Forty two patients belonged to Childs B. There were 39 bleeders (52%), 37 patients had variceal bleed as the fist indicator of liver disease. Amongst the bleeders, 13 patients (33%) had only one index bleed until the end of the study period (26 months) sclerotherapy (EST) controlled the bleed in 23. The average number of sessions required for reducing the grade of varices by one was six. Fundal variceal obliteration was necessary in the operated patients. In the non-bleeders (36), the mean follow-up period was 25 months. Twelve patients had no oesophageal varices; and 23 had either grade II or III oesophageal varices; those with grade III varices were on prophylactic propanolol.

Conclusions : One-third patients do not bleed after the first bleed related mortality is low; the rebleed or second bleed occurs after a mean interval of four years. The non-bleeders do not bleed for at least two years after diagnosis.

   
 

1200 - 1330 hrs.
Hall F : Case Reports

   

28.

Young Hypertensive : A Rare Cause

 

A Satish Kumar, Manisha Ganguly, VA Raviraj, NR Rau - Department of Medicine, Kasturba Hospital, Manipal - 576 119.

 

Case : A 20 years old male, 2nd sibling of five children was referred to our hospital for uncontrolled hypertension and pain in the abdomen. He was diagnosed to have hypertension at the age of three years and was treated with various medications. He had evidence of accelerated skeletal maturation with adult short stature and associated skeletal abnormality in the form of bilateral genu verum and broad wrists. His height was 135 cms, upper segment - 78 cms, lower segment - 57 cms, arm span - 140 cms and BMI was 24. History was suggestive of precocious puberty. Grade III hypertensive retinopathic changes were present in both eyes. Patient was thoroughly investigated for the etiology of his presentation. Twenty four hour urinary creatinine, estriol, b-HCG, catecholamines and VMA were within normal limit. Urinary ketosteroids were markedly increased. Serum T3, T4, TSH, LH and FSH levels were within normal limits. Ultrasound of abdomen revealed multiple hypoechoeic lesions in the suprarenal area. CT scan abdomen showed marked bilateral symmetrical adrenal enlargement with smooth borders consistent with congenital adrenal hyperplasia (CAH). The urinary and plasma steroid findings suggested the diagnosis of CAH due to 11-b hydroxylase deficiency.

Conclusion : Hypertension is a prominent feature of various endocrine diseases including congenital adrenal hyperplasia (CAH) due to adrenal enzymatic deficiency like 11-b hydroxylase. It is an autosomal recessive disorder and is a relatively infrequent cause of CAH. The hypertension is due to the accumulation of the mineralocorticoid deoxycorticosterone. In view of the severity of the clinical expression and complications, physicians should be aware of the disease and have a high index to suspicion in order to detect and treat such patients early enough to avoid or minimize the unwanted sequelae.

   

29.

Hashimoto’s Encephalopathy - A More Common Disorder than Hitherto Recognized

 

Manisha Ganguly, VA Raviraj, NR Rau - Department of Medicine, KMC Manipal - 576 119.

 

Introduction : Hashimoto’s encephalopathy (HE) is a subacute, steroid-responsive relapsing encephalopathy associated with autoimmune thyroiditis. Unlike encephalopathy associated with hypothyroidism, HE responds to steroid therapy and not thyroxine replacement alone.

Case : We describe a 49 years old female patient who presented with subtle bilateral cerebellar involvement with minimal thyroid enlargement. Thyroid function tests revealed evidence of gross hypothyroidism Hashimoto’s thyroiditis was discovered on FNAC. She was started on thyroxine replacement therapy but showed gradual cognitive decline. Over a period of two weeks, she developed frank features of pseudodementia. She also had two episodes of generalized tonic-clonic seizures, stupor and coma followed by respiratory arrest requiring ventilator support.

At no point of time, patient had any features of hypotension, hypothermia or electrolyte disturbance (hyponatraemia). CSF examination revealed high protein levels without pleocytosis. CT and MRI of the brain were normal. EEG showed diffuse slowing of waves consistent with encephalopathy. A diagnosis of Hashimoto’s encephalopathy was made and it was substantiated by the demonstration of high titers of anti-thyroid antibodies (anti-thyroid peroxydase, anti-thyroglobulin). Along with the thyroxine replacement, she was started on high dose of corticosteroid therapy (prednisolone 1.5 mg/kg body wt.) that resulted in dramatic clinical improvement.

Conclusion : Hashimoto’s encephalopathy should be recognized as a distinct neurological entity and added to the list of CNS complications of thyroid disease and must not be confused with myxoedema coma. It should also be entertained as a differential diagnosis of other encephalopathies especially in unexplained neurological deterioration.

   

30.

Central Diabetes Insipidus in a Case of Migraine - A Case Report

 

A Rohatgi, KK Yadav, S Garg - Department of Medicine, Lady Hardinge Medical College, New Delhi.

 

A 34 years married housewife with a 12 years history of "classical migraine" was referred to our hospital with complaints of polyuria and polydypsia since two months. The patient had two uneventful pregnancies and childbirths in the past 10 years and did not suffer from any mental or other medical illness.

Two months prior to presentation, following a severe attack of migraine associated with transient loss of consciousness, her complaints of polyuria and polydypsia started. Physical examination did not reveal any neurological abnormalities or signs of hypopituitarism. Routine investigations did not reveal any abnormality. After the preliminary investigations, a provisional diagnosis of Central diabetes insipidus was entertained and confirmed after carrying out a water deprivation test. Assays for anterior pituitary hormones were normal. Investigations to find out any underlying cause for diabetes insipidus were non-contributory. MRI of the brain revealed a normal stalk and anterior pituitary but there was loss of the normal bright signal (on T1 images) of the posterior pituitary. A final diagnosis of complicated migraine leading to central diabetes insipidus was made and patient was started on oral carbamazepine which resulted in marked improvement of her symptoms.

Central diabetes insipidus (CDI) is usually idiopathic in nature; trauma and tumours of the skull, metastases, granulomas and meningitis constitute the common secondary causes. Infarction of the brain leading to focal neurologic deficits, associated with episodes of migraine have been termed as "complicated migraine". Arterial vasospasm, hightened platelet aggregability and increased blood coagulability have all been incriminated as the pathophysiologic mechanisms involved in migranous infarction. Our patient developed CDI following a severe attack of migraine which was diagnosed by clinical features, water deprivation test and MRI of the brain. The patient probably had selective dysfunction of posterior pituitary following the migranous attack which resulted in CDI. The association of CDI with migraine has not been previously reported.

   

31.

Hypertensive Encephalopathy Causing Obstructive Hydrocephalus

 

R Dewan, R Rai, S Khatri, R Anand, VK Goyal, P Gupta - Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi - 110 002.

 

Hypertensive encephalopathy (HTE) usually causes supratentorial white matter edema, mainly involving posterior regions of cerebral hemisphere. Rarely, edema of posterior fossa structures namely cerebellum and brain stem has been described. Obstructive hydrocephalus consequent to posterior fossa swelling is reported in isolated cases. We report a case of 15 years old boy presenting with headache, vomiting, loss of consciousness and seizures for two days. His previous medical history and records revealed that he was hypertensive and was diagnosed to have chronic glomerulonephritis for last one and a half months, but was not on regular treatment. On examination patient was comatosed and his blood pressure was 220/180 mmHg. Neurologically he had sluggishly reacting semidilated pupils, hyperreflexia and extensor planter response. Fundus examination revealed papilloedema. Laboratory investigations showed a hemoglobin of 6 gm/dl and neutrophil leucocytosis. Blood urea was 80 mg/dl and serum creatinine was 2.1 mg/dl. Urine analysis revealed moderate proteinuria and occasional RBCs. Chest X-ray suggested pneumonitis in right middle zone. CT scan of head showed bilateral, multiple, ill defined hypodensitis in cerebellar white matter extending to cortex, and in pons, with effacement of basal cistern and fourth ventricle, suggestive of obstructive hydrocephalus. Patient was aggressively treated with intravenous nitroglycerine, dexamethasone, furosemide and mannitol. Ventricular drainage was also performed. However, patient did not recover and died on third day of admission.

   

32.

Amyopathic Dermatomyositis - Report of Three Cases

 

K Shawmuganandan, KV Singh, NK Bhandari, DS Bhakuni, R Kakkar, US Kumararel, S Narayanan - Command Hospital (SC) Pune - 411 040.

 

Introduction : Amyopathic dermatomyositis (ADM) is a rare variant of dermatomyositis that is characterized by the typical skin rash but without myositis.

Methodology : We studied clinicopathological characteristics of three patients with amyopathic dermatomyositis. It was a retrospective study conducted in Rheumatology Centre, Command Hospital, Pune.

Summary of Results : The subjects comprised of two women and one man. The average age was 31.2 years. All had skin rash specific for dermatomyositis, but had so signs of myositis. The various common clinical manifestations were polyarthritis, fever, photosensitivity, fatigue and interstitial lung disease. Two patients had features of myocarditis and Raynaud’s phenomenon. There was no evidence of myositis clinically, by muscle enzyme estimation, EMG or by muscle biopsy in all the three cases. Skin biopsy findings were suggestive of dermatomyositis with perivascular inflammation and vasculitis. Cardinal cutaneous manifestations comprised of heliotrope rash, malar rash, vasculitic ulcers, Gottron’s papule and shawls sign. The laboratory profile revealed raised markers of inflammation like, ESR, CRP. ANA by immunoflouresence was positive in one out of three cases. ANA profile revealed raised Anti-Jo1 antibody in one case during a follow-up period ranging from 12- to 38 months (average, 25.3 months), none developed any evidence of myositis. All were treated with oral steroids (prednisolone 1 mg/kg) and chloroquine. Two patients were put on immunosuppressive (Azathioprine). None had evidence of associated malignancy.

Conclusion : Thus amyopathic dermatomyositis is a rare subset of inflammatory myopathy with a distinct clinical profile.

   

33.

Primary Pulmonary Lymphoma : Presenting as Lung Masses

 

GC Khilnani, A Kumar, P Gupta, N Bhatta, OP Malhotra, SD Gupta - Department of Medicine, Surgery, Pathology, All India Institute of Medical Sciences, New Delhi - 110 029.

 

Primary pulmonary lymphomas (PPL) are rare lesions of lung which are difficult to diagnose. The symptoms and signs are non-specific and so is radiology. Hence lung biopsy gives the answers. Bronchoscopic biopsy may not be diagnostic. We have come across two cases of PPL diagnosed on OLB.

Case - 1 : A 75 years, non-smoker housewife presented with five months history of shortness of breath, dry cough chest pain, and easy faiguability. There was no history haemoptysis. Examination of chest revealed signs of mass on left side. X-ray and CECT of the chest revealed a mass lesion in the left lower lobe with minimal pleural effusion. Sputum, bronchoscopic aspirate and biopsy, and percutaneous FNABC were inconclusive. Patient was subjected to exploratory thoracotomy. At surgery there was a hard mass of 6 x 6 cm size in the left lower lobe extending up to secondary carina. A left pneumonectomy was performed. On histopathology a diagnosis of non-Hodgkin’s lymphoma was established and patient was put on chemotherapy (CHOP). No other site was involved.

Case 2 - A 14 years girl presented with history of low to mederate grade fever for two and half months. She had Hb of 7.7 gm/dl with TLC of 15,300/cu mm with 85% neutrophils, X-ray of the chest and CT revealed pneumonic consolidation and multifocal abscess formation in the right upper lobe. She received ATT without any response. Sputum, bronchoscopy and percutaneous biopsy were inconclusive. Patient was lost to follow up and two months later the CT revealed increased area of consolidation. She underwent thoracotomy and at surgery there was a mass in the right upper lobe involving chest wall and mediastinum encasing the vascular pedicles. Only biopsy could be done. The histological examination of mass revealed Hodgkin’s lymphoma. No other site was involved on work up. Patient was treated with chemotherapy (ABVD, six cycles), followed by radiotherapy. There was clearance of lung shadow and patient became asymptomatic. On follow up for a period of two years patient was asymptomatic and there was no evidence of recurrence.

In the first patient pre-operative diagnosis was bronchogenic carcinoma and in second atypical infection was probable cause. Pulmonary involvement in lymphoma is rare. The diagnosis of PPL in this case was based on the criteria described by L’Hoste which is a modification of original Salzestein criteria. Two pre-requisite features are : 1) involvement of lung, lobar or main stem bronchus either unilaterally or bilaterally with or without hilar or mediastinal involvement, 2) no evidence of extrathoracic lymphoma at the time of diagnosis or for three months following diagnosis. Primary lymphomas arising from the bronchus associated lymphoid tissue (BALT) are accounting for 3.6% of all extranodal lymphomas and less than 1% of all malignant lymphomas. The lung ranks as the 10th commonest site for Hodgkin’s lymphoma. A history of inflammatory or autoimmune disorder may be present. The treatment of primary pulmonary lymphoma is surgical as suggested by Salzestein. Treatment depends on the stage of disease. In early stage there is no role of adjuvent radiotherapy or chemotherapy following complete resection. Good symptom control and radiological response was achieved with chemotherapy in disseminated low grade lymphoma by Toh et al. Our both the patients had extensive disease and required surgery and chemotherapy. High index of suspicion and consideration of OLB or thoracoscopic biopsy would help in early diagnosis and appropriate management.

   

34.

Bilateral Adrenal Metastases from Large Cell Carcinoma of Lung in a Female Non-smoker Patient

 

PP Roy, KB Patra, S Dasgupta - Medical College, Calcutta.

 

A female patient aged 46, staying in the rural area of Midnapore, West Bengal presented with pain in the back of right lower part of chest for three months, occasional fever for one month and bilateral upper abdominal pain for one month. On general survey the patient was conscious, co-operative and alert, moderately anaemic, clubbing absent, no significant lymphadenopathy anywhere. Respiratory system examination - inspection and palpation - nothing significant. Percussion note - dull in the right infrascapular area. Breath sound - diminished vesicular in that area of dullness in the right side. Left side of the chest - normal findings. Gastro-intestinal system - abdomen soft, liver and spleen - not palpable No free fluid in abdomen, no palpable abdominal lymph node. Nervous system and cardiovascular system - NAD.

X-ray chest PA and right lateral view showed a rounded homogeneous opacity with smooth margin in the posterior aspect of right lower zone. USG of thorax - no evidence of fluid in the SOL of right lung. CT guided FNABC - large cell carcinoma of lung. USG of abdomen - bilateral SOL in adrenal glands. CT guided FNABC of adrenal gland showed evidence of metastases.

Bilateral adrenal glands metastases from lung cancer is rarely seen in clinical practice. Most of the patients of adrenal metastases from lung cancer remain asymptomatic. Features of endocrinopathy including Addison’s disease are uncommon as metastases usually occurs in medulla. Thus most of these patients are diagnosed only during autopsy. A high degree of suspicion is required to diagnose such patients while alive.

   

35.

A Case Report of A Rare Lipid Storage Disorder : Neimann - Pick’s Disease Type C

 

FR Nadri, A Rodricks, Sara Chandy, S Sankar - Department of Medicine, St. John’s Medical College Hospital, Bangalore - 560 034.

 

Neimann-pick’s disease is a lipid storage disorder with autosomal recessive inheritance due to deficiency of the enzyme sphinogomyelinase.

We report a case of 22 years male a product of first degree consanguineous marriage who presented with history of abdominal distension since two years with globally delayed milestones. Examination revealed pallor, icterus with massive hepatosplenomegaly with mental retardation and right gaze paresis.

Investigations revealed pancytopenia, elevated LDH, unconjugated hyperbilirubinemia. Haemolytic workup was negative and viral markers were negative. Bone marrow aspiration and biopsy was done which confirmed the diagnosis of Neimann-Pick’s disease because of large histiocytes with single nucleus and abundant vacuolated cytoplasm and an eccentrically to centrally placed nucleus.

The case reported by us in Neimann-Pick’s disease type C which is suggested by the triad of gaze paresis, hepatosplenomegaly and foam cells in the bone marrow. The rare Neimann-Pick’s disease type C patients may survive into adulthood.

Therapeutic strategies consisting of bone marrow and liver transplantation have been attempted with limited success. However, gene transfer using bone marrow progenitor stem cells carrying a copy of usual gene and enzyme replacement therapy appear promising for the future.

   

36.

Persistent Encephalopathy Following Cerebral Malaria

 

LK Dash, RK Dalai - SCB Medical College, Cuttack, Orissa.

 

Out of 255 cases of slide positive cerebral malaria studied over the last five years, there were 45 deaths and out of 210 cases, who survived, none had persistent neurological sequealae, the recovery of consciousness was well anticipated and complete with full recovery of intellectual and cognitive function. One case behaved differently. The patient herself a doctor and a post-graduate student of O and G of this college presented with a five day fever for which she took Nimesulide and Cefadroxil. She went on to develop unconsciousness on the 5th day of her fever, when a blood test for MP by QBC method showed ++++ parasitemia and was soon put on IV Quinine. She was transferred to VSS Medical College, Burla, after 2nd dose of quinine. Her unconsciousness worsened after the 3rd dose of quinine, although most biochemical parameters were normal, but ++++ parasitemia over the next 24 hours. She was put on doxycycline and Artesunate. She also received 3rd generation cephalosporin for 10 days. Parasitemia cleared on the 4th day of starting quinine therapy but she remained fully unconscious with only slight response with eye opening to deep painful stimuli. The features of encephalopathy such as altered sensorium, confusion, disorientation; inability to make a speech, decreased thought content, bizarre limb movement with extrapyramidal rigidity all persisted up to 25th day. CSF study and CT scan on two occasions were persistently normal except hypodense lesions on 2nd CT scan. Causes of persisting encephalopathy following cerebral malaria will be discussed. Coexistent viral encephalitis causing post-encephalitic sequealae is a possibility, which will also be discussed.

   

37.

Association of Falciparum Malaria with Acute Transverse Myelitis

 

RK Singh - District Hospital, Daltonganj, Jharkhand.

 

A 35 years female patient presented weakness of lower limbs two days. Weakness progressed to complete palsy in 24 hours time. She had fever with chills for the last six days prior to her neurological complaints. Clinical examination revealed flaccid paraplegia with sensory loss (both pain-temp. and vibration) upto D8 and retention of urine (e.g. spinal shock). Investigation —— FBC showed WBC 7600/cumm, P 60% L 36% E 3% M 1% and Hb 10.8 gm/dl. ESR was 40 mm in first hour. Peripheral blood smear showed ring stage of P. falciparum. X-ray spine was normal. CSF examination revealed no abnormality and VDRL was negative. Blood sugar and BUN were normal. Serum antinuclear factor and ELISA test for HIV infection were negative. She was given chloroquine IM injection in standard dose along with steroid. She became afebrile on the third day of treatment and gradually regained power in lower limbs. She was able to walk after two weeks.

Rosetting of infected and non infected RBCs as well as cytoadherance of infected RBCs are the two phenomena which can probably explain the development of myelitis like picture.

   

38.

Pyopneumopericardium Following Ludwig’s Angina

 

R Dewan, R Rai, S Khatri, V Singh, VK Goyal, P Gupta - Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi - 110 002.

 

A 45 years female presented with chest pain, breathlessness and cough with purulent expectoration. She had a history of dental caries with Ludwig’s angina five days back, which was inadequately treated. On examination, she was febrile, tachypnoeic, BP was 100/80 mmHg and heart rate was 124 beats/min. She had a raised JVP and on abdominal examination tender hepatomegely was present. Chest examination revealed right sided basal crepitations. Cardiovascular examination revealed increase in area of cardiac dullness, muffled heart sounds and a characteristic crunch on auscultation over precordium. Blood test showed anaemia with neutrophil leucocytosis. X-ray chest showed right basal pneumonia and an air-fluid level in pericardium. A pericardiocentesis was performed which showed pus but no organism was isolated. A diagnosis of pyopneumopericardium was made and CT scan of neck and chest was performed to ascertain the possible etiology. It revealed pockets of air extending from submandibular space along facial planes of neck to anterior mediastinum and pericardium. Pyopneumopericardium due to descending necrotizing infection through fascial planes secondary to deep neck space infection like Ludwig’s angina is extremely rare and is reported in isolated cases. Though some cases of pyopneumopericardium need surgical debridement, our case was successfully treated with intravenous penicillin, metronidazole and third generation cephalosporin.

   

39.

Tuberculous Liver Abscess Mimicking Amoebic Liver Abscess

 

R Dewan, S Khatri, V Singh, R Anand, VK Goyal, P Gupta - Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi - 110 002.

 

A 25 years male presented with high grade fever, diarrhoea and pain in right hypochondrium. On examination patient was cachexic, moderately pale and a soft, tender liver was palpable 2 cm below costal margin. Investigations revealed hemoglobin of 7.4 gm/dl, ESR 140 mm in first hour and serum alkaline phosphatase of 24 KA units, other hematological and biochemical parameters being normal. Chest X-ray was normal. Ultrasonography of abdomen showed an abscess, 3.5 x 2.5 cm in size, in right lobe of liver. Amoebic serology was negative. Pus aspiraed from liver abscess revealed, caseating granulomas, with stain for AFB positive. A diagnosis of tuberculous liver abscess was made and patient was put on initial four drugs anti-tubercular therapy. Remarkable clinical improvement with weight gain, remission of fever and abdominal pain, and decrease in size of liver abscess was noted at 20 days of follow up. In patients of tuberculosis, diffuse involvement of liver with 0.6 to 2 mm diameter granulomas is common. A few may have focal lesion, either conglomerate tubercles or very rarely a hepatic abscess, which my pose diagnostic difficulties.

   

40.

Multiple Splenic Abscesses : An Unusual Cause

 

Shivashankar, DMR J Raju, K Ramakrishna, P Shetty, GK Varghese - Department of Medicine, Kasturba Medical College, Manipal.

 

Various etiologies have been reported as the causation of splenic abscess. We recently cared for a patient with multiple splenic abscess with an unusual cause.

Case Report : A 45 years woman, a known diabetic presented with PUO of eight weeks duration and pain in both knees. Clinical examination revealed moderate jaundice and firm hepatomegaly, tender and soft spleen which was palpable about 3 cms and bilateral moderate pleural effusion. Laboratory tests revealed leucocytosis, high blood sugars and markedly elevated alkaline phosphatase, blood cultures revealed pseudomonas, considered as contaminant. USG abdomen showed hepatomegaly and splenomegaly with multiple abscesses. Pleural aspirate was transudate, CT abdomen confirmed the multiple splenic abscesses and liver of uniform texture. She was treated initially with vancomycin, ceftriaxone and metronidazole.

However, her fever was persisting so we opted to do CT guided aspiration of splenic abscesses to get an etiologic diagnosis. Frank yellowish pus was aspirated and cultures revealed Burkholderia pseudomallei which was confirmed by biochemical characteristics and was sensitive to ceftazidime, co-trimoxazole and doxycycline.

Therapy was changed to high dose ceftazidime and co-trimoxazole. Patient’s condition improved dramatically and was asymptomatic. Repeat chest X-ray was normal, USG abdomen showed resolution of splenic abscesses. Patient was discharged with advice to continue co-trimoxazole for six more months. Patient is on follow up and doing well.

Final Diagnosis : Melioidosis as multiple splenic abscesses.

   

41.

Histoplasma capsulatum Presenting as PUO - Bilateral Adrenal Masses

 

UC Kansra, R Mahajan, S Bhandari, VH Talib et al - Safdarjung Hospital, New Delhi.

 

A 60 years male resident of Bihar presented with low grade fever of six months and cough with expectoration and weight loss of three months duration. He was a smoker, non-diabetic and nonhypertensive. His records revealed mild iron deficiency anaemia with leukopenia. X-chest was normal. Bone marrow and splenic aspirate were negative for LD bodies. Sputum was negative for AFB. Since he was a resident of Bihar hence he was earlier treated for Kala-azar and as he did not improve he was put on trial of antitubercular therapy at his native place in Bihar. On examination he had low grade fever with hepatosplenomegaly. All routine investigations were within normal limits except for anaemia. Ultrasound and CT of abdomen revealed hepatosplenomegaly, bilateral adrenal masses and multiple gall stones. Ultrasound and CT guided FNAC from the adrenal masses revealed plenty of intracellular oval bodies having a halo around them. They were found within foamy macrophages as well as lying in branches extracellularly. The patient was negative for HIV. The patient was diagnosed as a case of disseminated histoplasmosis, as bilateral adrenal involvement is a typical presentation. Bilateral adrenal enlargement on ultrasound or CT in a patient with PUO is a good clue to the diagnosis. The patient was put on fluconazole and he responded well to the treatment, and within few weeks became asymptomatic. Repeat ultrasound after six months showed that size of adrenal masses had regressed considerably. He is under regular follow up and at present has no symptoms.

   

42.

Idiopathic Erythrocytosis - A Rare Cause of Cortical Venous Sinus Thrombosis in a Young Male

 

M Krishnakumar, D Das, MV Nagaraja - Kasturba Medical College, Manipal, Karnataka.

 

A 30 years male patient was admitted with history of headache of one month duration, weakness of left half of the body of two days duration and convulsions of one day duration. Headache was continuous, generalised and moderate in intensity. There was no associated convulsions or blurring of vision. Two days prior to the admission the patient noticed weakness of left upper limb followed by weakness of left lower limb which progressed to complete paralysis in about seven hours. After four hours patient also had convulsions which originated from left upper limb and later become generalised. There was no history of fever, bowel and bladder involvement, head injury, ear infection or TIA. Patient was not a smoker or alcoholic. General physical examination was remarkable for presence of conjunctival congestion. On neurological examination, the patient had left UMN type of facial palsy and upper motor neuron type of weakness of grade 3/5 on the left upper and lower limbs.

On investigations, his haemoglobin was 18.7 gm% with a haematocrit of 53.1%. The total leucocyte count, differential count, platelet count, ESR and blood smear study were normal. The blood sugar, liver function tests, renal function tests, bleeding time, clotting time, prothrombin time and activated partial thromboplastin time were also normal. His ultrasonogram of abdomen, chest X-ray and arterial blood gas analysis were normal. A CT scan of the head was done which showed irregular, superior, sagital sinus with a positive empty delta sign with hemorrhage in the right subcortical region. A magnetic resonance venogram showed evidence of superior sagital sinus thrombosin with intracerebral haematoma. Anti-dsDNA antibody, anti-nuclear antibody, antiphospholipid antibody were negative. Urine examination for homocystinuria was negative. Serum fibrinogen, vitamin B12 levels were normal. Serum erythropoietin level was normal. Bone marrow examination, Doppler study of carotid and vertebral arteries, echocardiogram were also normal.

The patient was treated with low molecular weight heparin, phlebotomies, phenytoin sodium and antioedema measures. He recovered completely within eight days and was discharged with advice to continue warfarin, phenytoin and low dose aspirin. His hemoglobin was maintained at 13.8 gm%. The patient was followed up regularly and was asymptomatic.

Idiopathic erythrocytosis is a rare and distinct haematological entity of unexplained polycythemia. This group forms about 20% of all cases of polycythemia. The serum erythropoetin level is normal in idiopathic erythrocytosis unlike both primary and secondary polycythemias where the erythropoietin levels will be low or high respectively. The patients with idiopathic erythrocytosis have more incidence of vascular complications where cerebrovascular accidents may be the presenting feature.

   

43.

A Case Report of Unusual Presentation of Acute Myeloid Leukaemia

 

D Dadhich, K Kothari, S Mehta, K Deepak - Department of Medicine, SMS Medical College, Jaipur.

 

A 10 years male child was admitted to our ward with presenting C/o bulging of both eye balls since one month, dimness of vision in right eye, and complete loss of vision in left eye since 10 days. He also had h/o low grade fever off and on since 2-3 months and significant weight loss during this period. On examination, patient was febrile, pulse 80/mt, BP 120/80 mm Hg, sternal tenderness (+), pallor (+), gen lymphadenopathy (+), both eyes were protruded, conjunctiva was suffused in both eyes, cornea was hazy, projection of rays and light (+). A hard palpable mass was present behind upper eye lids of both eyes. Fundus showed hazy media, widespread haemorrhages, both intra and preretinal, multiple choroidal masses. Abdomen showed mild hempatomegaly. CNS, heart and lungs were normal.

Investigations showed marked leukocytosis - TLC was 219400, platelets 31000, ESR 170, PBF showed blast cells, auer rods (+), blast - 47% promyelocytes 3%, metamylocytes 5%, X-ray chest normal, USG abdomen showed mild hepatomegaly. Bone marrow biopsy revealed, AML M2 type. CT head excluded intracranial SOL causing proptosis. FNAC from the palpable mass behind upper eye lid, showed leukaemic blast cells.

Proptosis was due to chloroma in the retroorbital space. It was a rare presentation of AML. Chloromas are infiltration of leukaemic blast cells in soft tissues. In less than 1% of the cases patients may present with chloroma as a presenting feature before the bone marrow involvement occurs. Chloroma in retroorbital space is rarest presentation.

   

44.

A Rare Case Report of Mixed Polycythemia

 

A Gokhroo, SK Arora, AK Gupta, M Ram - JLN Medical College and Hospital, Ajmer.

 

Cases of mixed ploycythemia are rare presentation in clinical haematology. Incidence of polycythemia vera itself are 2/1,00,000 population. A 55 years female, non-smoker, hypertensive, follow-up case of bronchial asthma, presented with complaints of gradually progressive darkening of skin, redness of eyes, generalised pruritus (intense itching after exposure to water most typically during bath) urticaria and palpitation for five years. She complained of headache, fullness in head, dizziness, spots before the eyes, weakness, uneasiness, swollen tongue (off and on) for last five months. There was no history of living at high altitude. Past history revealed symptoms of chronic dyspnoea for 25 years, bleeding tendency and hypertension. On examination skin and mucous membranes were ruddy coloured, conjunctival vessels were congested, nail bed and palms were plethoric, pulse, BP normal (on drugs), respiratory rate 18 per minute, bilateral rhonchi and crackles present at bases, liver and spleen were about 3 cm below costal margins. Investigations - Hb was 25 gm%, TLC 19,200/mm3, DLC P90L10, ESR 1 in 1st hour, PCV 78%, RBC 7.1 x 106 per mm3, platelet counts 4.6 lac, PBF was suggestive of polycythemia. MCH, MCHC, MCV, BT, CT, INR and other routine investigations were normal. ECG showed LVH, ABGA-O2 saturation 90%. PFT - Moderate obstruction with mild restrictive pattern (on drugs). Erythropoeitin level 1.1 units/litre. A diagnosis of mixed polycythemia was made and she was continued on all symptomatic drugs and phlebotomies. She had marked improvement of her symptoms after phlebotomies. Polycythemia itself is rare entity and mixed polycythemia is even rare. Therefore high suspicion index is required because the disease in rare and symptoms are vague.

   

45.

Multiple Plexopathies in a Postsplenectomy Patient of Chronic ITP with Diabetes Mellitus

 

LH Ghotekar, Archana Dambal, TK Dutta, Vivekanandan, S Narayan - Jawaharlal Institute of Postgraduate Medical Education and Research, JIPMER, Pondicherry - 605 006.

 

A middle aged man underwent splenectomy for steroid responsive but dependent chronic idiopathic thrombocytopenic purpura. During the post-operative period he developed diabetes mellitus with ketoacidosis for which he was treated. During the same period his platelet counts failed to increase as expected. A blood coagulation profile and hemogram revealed features of chronic disseminated intravascular coagulation. A week later he developed weakness and sensory loss in the distribution of right brachial plexus, lower trunk of left brachial plexus. Nerve conduction studies demonstrated involvement of right common peroneal and left sural nerves. Patient made a remarkable recovery from his neurological involvement on treatment with corticosteroids, danazol and anticoagulants.

We speculate a common autoimmune process relating all the disorders that occurred in this patient.

   

46.

Acute Pancreatitis in OP Poisoning

 

R Balasubramanian, Kavitha Saravu, TI Khan - Kasturba Medical College, Manipal.

 

Twenty four years male, an agriculturist occupation presented with history of fever, vomiting, diarrhoea, excessive sweating, excessive salivation for two days following spraying metacid for two days in his form. He is not a known smoker or alcoholic with no history of prior medical disease. On examination he was conscious, oriented and found to have tachypnoea, tachycardia, normal blood pressure with bilateral constricted pupil. Gastric lavage fluid was smelling of organophosphorus compound. Investigation revealed leukocytosis, low cholinesterase level with normal RFT/LFT/ECG/CXR. HIV, HBsAg ELISA were negative. So, he was treated as a case of organophosphorus compound poisoning with atropine, pralidoxime, antibiotics. Three days later patient developed severe abdominal pain with gross abdominal distension with absent bowel sounds, was thought to have paralytic ileus secondary to atropine, amylase (505), lipase (2195) were found to be high USG abdomen revealed diffusely hypoechoic pancreas with bialteral pleural effusion with no evidence of biliary disease. His serum calcium, triglycerides were normal. So a diagnosis of acute interstitial uncomplicated pancreatitis was made secondary to organophosphorus compound.

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