1. Imatinib Mesylate Compared with Hydroxyurea in Patients with Chronic Phase Chronic Myeloid Leukaemia

PS Ghalaut, U Singh, V Singh, Deepali
Post Graduate Institute of Medical Sciences, Rohtak - 124001.

Background : Imatinib mesylate a-selective inhibitor of the BCR-ABL tyrosine kinase produces high response rates in patients with CML. It is a promising drug, used for targeted therapy in CML.

Material and Method : Thirty proved eases of CML in chronic phase were taken for the study. 15 patients each were treated with Hydroxyurea and Imatinib mesylate in standard doses respectively. A follow-up of 6 months was done.

Result : The clinical sign and symptoms improved in both the groups (in Hydroxyurea group in 2-3 weeks time while in Imatinib group in 4-6 weeks time). Cytogenetic response was observed in all the cases of Imatinib therapy. The patients on Imatinib therapy showed graded and sustained improvement as compared to Hydroxyurea group where the patients showed marked fluctuations in TLC. Three patients in Hydroxyurea group developed paneytopenia while no major side effects were observed in Imatinib group.

Conclusion : Imatinib mesylate therapy is superior to Hydroxyurea therapy in patients of CML in chronic phase.

2. Evaluation of Nutritional Statustribal ‘HO’

NK Sengupta, Soumya Sengupta
I Sen Charitable Hospital, Chaibasa - 833 201, Jharkhand.

Vivid picture are being brought forward after door to door survey on all over the area. There are specific deficiencies like protein, but Iron (Hb) contents, in blood is not definitely so low as compared to other races, which is definitely a significant character.

Daily living habit has got his own specialty. Though “Haria” is an intoxicated food, but they are accustomed with it as their daily food and which helps them in growth and development.

Results of Examination - a) Giardia-lambia : 3%. b) Entamoeba histolytica : 5%. c) Ancylostoma Duodenale : 30%. d) Necator Americanis : Nil. e) Hymenolepis Nan : Nil. f) Taenia Group : 2%. g) Ascaris Lumbicoides : 15%. h) Enterobius Vermicularis : Nil. i) Balantidium Coli : One Case.

Infant Mortality Rate. IMR is 52 per thousand.

3. Pyomyositis - A Rare Association in Hematological Disorder

TK Dolai, R Kumar, R Bhargava, M Mahapatra, P Mishra, T Seth
Haematology Department, All India Institute of Medical Sciences, New Delhi - 29.

Pyomyositis is an acute pyogenic infection of the skeletal muscle, usually accompanied by abscess formation. This disease may occur in all age groups, but reported cases have been mainly in children or patients with immunocompromised conditions such as human immunodeficiency conditions, diabetes mellitus, and in individuals living in temperate climates. Pyomyositis is a rare infectious disease that is difficult to diagnose. In this report, we describe our case (chronic lymphocytic leukemia) who presented with pyomyositis.

A 54 year old male presented with generalized lymphadenopathy and anemia of 2 months duration. On examination he had moderate pallor, generalized lymphadenopathy (size 3 x 4 cm bilateral cervical, 2.5 x 2 cm bilateral axillary, 3 x 3.5 bilateral inguinal), spleen palpable 10 cm, liver 2 cm. On Investigation: Haemoglobin 7.3 g/dl, white blood cell count 21,350/mm3 with NLME, platelets cont 10 8433 160,000/mm3. Base line biochemistry was normal. Bone marrow aspiration, biopsy and Immunophenotype were suggestive of CLL. He was received 8th cycle of fludarabine and cyclophosphamide. Two months later he was admitted with fever and pain in the left hip. On examination, soft tissue swelling of the left thigh with tenderness and restriction of movements of left hip. FNAC from lesion raveled infiltration of neutrophils. USG showed subcutaneous oedema, underlying heperechogenicity, muscles are hypoechoic, suggestive of myositis. MRI of thigh showed abscess with some debris in left quadriceps muscle with adjacent edema and loss of muscle planes, suggestive of pyomyositis. From aspirated materials methicillin resistent Staphylococcus aureus (MRSA) was grown. Blood culture and Gram’s stain were negative. Teicoplanin and amikacin were started and continued for 4 weeks before shifting to the oral form of ciprofloxacin for 2 weeks. He received regular follow-up at our hospital and there was no recurrent event of pyomyositis.

Pyomyositis should be included in the standard diagnostic procedure when suspected. Antibiotic therapy should initially cover S. aureus until the specific organism is identified. With early recognition and appropriate medical and surgical care, the treatment course can be shortened and morbidity and mortality can be avoided.

4. Vocal Cord Palsy in Aplastic Anaemia

R Bhargava, TK Dolai, R Kumar, M Mahapatra, P Mishra, T Seth
Department of Hematology, All India Institute of Medical Sciences, New Delhi - 29.

Trauma, malignancy, infection and neurodegenerative and neuromuscular diseases have all been reported to cause vocal cord paralysis. Iatrogenic injury of the recurrent laryngeal nerve is the most common cause of vocal cord paralysis. We report a case of bilateral vocal cord paralysis and respiratory obstruction caused by compression of the recurrent laryngeal nerves by haematoma.

A 38 yrs male patient was diagnosed as serve aplastic anemia. He was on cyclosporine. Two months later patient was admitted with progressive swelling of neck, fever around 101oF, shortness of breath and bleeding from gum, nose of two days duration. On examination : severe pallor, inspiratory stidor, hoarseness of voice, diffuse swelling of neck more in left side, purpura in trunk and extremity, blood pressure 110/70 mmHg. On investigation: SPO2 84%, Hemoglobin 5.6 g/dl, Total leukocyte counts 1240/cmm with an absolute neutrophil counts 252/cmm, Platelet counts 4000/cmm. Base line chemistry was normal. Soft tissue X-ray of neck and chest X-ray were normal. Laryngoscope and flexible fiber optic endoscope showed restricted movement of left vocal cord, right vocal cord was normal. Contrast enhanced CT (CECT) of neck revealed ill defined focal soft tissue mild heterogeneous mass lesion involving left pyriform sinus region with mild compression and narrowing of supraglotic airway? haematoma.

Patient was treated with moist O2 inhalation, tranexamic acid, packed cells and platelets transfusion. He also received amikacin, cefoperazone and sulbactum. Three days after treatment, SPO2 was gradually normalized and disappearing of stridor. Hoarseness of voice was disappearing after 9th days of treatment. Repeated Laryngoscope and flexible fiber optic endoscope showed normal movement of left vocal cord. Contrast enhanced CT (CECT) of neck revealed resolving focal soft tissue heterogeneous mass lesion without compression and narrowing of supraglotic airway?resolving haematoma. Subsequently patients was discharged after Antithymocyte globulin infusion. No adverse respiratory symptom was documented three months of follow up.
In conclusion, although rare, haematoma may cause unilateral or bilateral vocal cord paralysis and respiratory obstruction, and should be considered in the differential diagnosis of vocal cord paralysis in relevant clinical setting.

5. Case Report Hemochromatois in A Patient with Hereditary Spherocytosis

M Shetty*, IR Varaprasad+, B Sudarshan+, A Srirang#, P Krishna**, VR Srinivasan***, MVS Subbalakshmi*, N Chandra*
*Assistant Professor; +Post Graduate; #Senior Resident; **Associate Professor; ***Professor, Department of Medicine, Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad 500 082.

18 year adult born of non consanguinous marriage, a known case of hereditary spherocytosis status post splenectomy and post cholecystectomy, was admitted with vomitings of 10 days duration and progressive jaundice of 2 mths duration. He received 10 transfusions of packed red cells till date. His sister also has spherocytosis, status post splenectomy. He had pallor, deep icteus, hyperpigmentation of the body with no stigmata of chronic liver disease. Hepatomegaly was present.

He was investigated for the cause of jaundice. He had total bilirubin of 60 mg/dl, conjugated fraction of 26 mg/dl, ALT (SGPT) was 290 IU/ml, and AST (SGOT) was 641 IU/ml. His virological markers for Hepatitis B, C and other viruses were negative. Workup for Wilson’s disease, Primary Biliary Cirrhosis and auto immune hepatitis were negative. ERCP was done and sludge was cleared from Common Bile Duct. Serum Ferritin was greater than 1500 ng/ml. Serum transferrin was 286 mcg/ml (220-400) and Transferrin saturation was 85%. Hemochromatosis was suspected after evaluation.

He was admitted and was planned a liver biopsy and genetic studies. Patient developed septic shock during the hospital course and succumbed.

Post mortem liver, kidney and testicular biopsies were done. Post mortem liver biopsy showed liver parenchymal iron accumulation with minimal accumulation in the reticuloendothelial cells suggestive of Hemochromatosis.

Conclusion : Hemochromatosis is seen in certain families with hereditary spherocytosis. Symptomatic iron overload has been reported in Spherocytosis patients who are heterozygous for the hemochromatosis gene. After larger studies are performed and published, it will be possible to estimate the prevalence of one or more hemochromatosis gene mutations in subjects who have hereditary spherocytosis. We report here a rare case of Hemochromatosis in Hereditary spherocytosis reported in the West but not reported till date in our country.

6. Pancytopenia : Clinical and Aetioilogical Profile

AK Choudhury, R Mohanty, SN Das, PK Das, MR Behera, N Srinibas
SCB Medical College, Cuttack, Orissa 753007.

Aims of Study : To study the clinical and etiological profile of patients with pancytopenia.

Methods : 59 cases (36 male + 23 female) of pancytopenia above age of 14 years after all exclusion criteria were included in the study. Detailed clinical evaluation, complete haemogram were performed prior to blood transfusion. Bone marrow aspiration cytology was done when in all cases and bone marrow biopsy was done in 4 cases when aspiration material was insufficient.

Observation : Out of 59 cases, majority i.e. 28 cases (45%) were in the age group of 14-30 years. They presented as fever in 9 cases (15.3%), shortness of breath and fatigue in 7 cases (11.9%), bleeding manifestation in 1 case (1.7%), and rest 42 cases (71.2%) presented with combination of above features. Clinical examination revealed pallor in 59 cases (100%), petechiae in 23 cases (39%), splenomegaly in 15 cases (25%) hepatomegaly in 12 cases (12.3%), sternal tenderness in 4 cases (6.8%), lymphadenopathy in 1 case (1.7%). Detailed hematological study revealed aplastic anemia in 40 cases (67.8%), acute leukemia in 10 cases (16.4%). Hypersplenism in 3 cases (5.1%), megaloblastic anemia in 3 cases (5.1%), myelodyplastic syndrome in 2 cases (3.4%).

Conclusion : Pancytopenia should be suspected in any patient with anemia, pyrexia of unknown origin and/or bleeding manifestation. A meticulous peripheral blood smear examination is an invaluable tool for diagnosis. Bone marrow aspiration cytology is sufficient for establishing diagnosis in majority of patients with pancytopenia. Aplastic anemia, acute leukemia, hypersplenism, myelo dysplastic syndrome, megaloblastic anemia are the common aetiologies. Aplastic anemia and Acute leukemia are common in younger age group (< 30 years) where as MDS, Hypersplensim and Megaloblastic anemia are common in older age group (> 45 years).

7. Intrabronchial Obstruction Due to Blood Clots - A Rare Cause of Breathlessness in a Patient with Hemophila

R Varaprasad, M Talluri, Rangaraman, S Abkari, MVS Subbalaxmi,
M Shetty, A Krishnaprasad, VR Srinivasan
Nizam’s Institute of Medical Sciences, Hyderabad.

A 56 year-old male, non-smoker, a known case of haemophilia A, with a baseline factor VIII level of 10% came with three episodes of haemoptysis followed by breathlessness of one day duration. There was no history of chest pain, wheeze, fever, loss of weight or appetite, or trauma to chest. He had pulmonary tuberculosis 14 years ago, and a previous episode of hemoptysis 10 years ago which was managed conservatively. At presentation he had tachypnoea, tachycardia, crepitations in left infrascapular area and diminished breath sounds in right infrascapular area. Spo2 on room air was 92%. Chest radiograph taken on day 1 was unremarkable. He was given factor VIII, aiming a level of 40%. On the next day breathlessness and hypoxia worsened. Examination showed diminished breath sounds in right interscapular, infrascapular, infraaxillary areas, chest radiograph showed haziness in right mid and lower zones. CT Chest showed intra-bronchial obstruction in right middle and lower lobe. Fibreoptic bronchoscopy confirmed the blood clots and clot retrieval was done piece meal with which he improved significantly.

This case highlights a rare complication in hemophilac i.e. intrabronchial obstruction due to blood clots and the successful removal with fibreoptic bronchoscopy.

8. Foreign Body Aspiration - A Rare Cause of Recurrent Respiratory Infections

M Talluri, S Abkari, Rangaraman, MN Rao, YSN Raju
Nizam’s Institute of Medical Sciences, Hyderabad.

We present a case of a 25-yr-old lady who presented to us with recurrent episodes of respiratory tract infections since childhood associated with streaky hemoptysis. There was no history of cardiac disease.

Clinical examination showed bilateral clubbing and crepitations in left basal area. Chest radiograph showed a retrocardiac opacity and high resolution CT scan confirmed left lower lobe collapse with bronchiectatic changes. Fibreoptic bronchoscopy showed a plastic foreign body embedded in left lower lobe bronchus. It was removed with the fibreoptic bronchoscope. It turned out to be a toy whistle which she had aspirated at the age of 8 years while playing with a toy. Thus she had a foreign body in her left lower lobe for 17 long years prior to being discovered.

She subsequently underwent a left lower lobectomy for the diseased lobe and is doing well on follow up.

This case highlights the need for high suspicion of foreign body aspiration in children presenting with recurrent respiratory infections.

9. A Study of The Clinical Profile of Megaloblastic Anemia in Tertiary Care Hospitalo

Roja Joseph, Shubha Seshadri
Kasturba Hospital, Manipal.

Introduction : Hyperhomocytinemia is a risk factor for cardiovascular accidents and one of the reversible risk factor for hyperhomocystinemia is vitamin b12 and f ‘olate’ deficiency. As cardiovascular diseases are emerging as an megaloblastic anemias a potential correctable cause of hyperhomocystinemia anchors its importance.

Aims : to study the clinical and hematological profile of megaloblastic anemia.

Material and Methods : this prospective study was conducted in Kasturba Hospital, Manipal between September 2006 and May 2007 for 8 months period. 40 bone marrow proven cases of megaloblastic anemias was included in the study.

Conclusions : Vegetarian diet was found to be the major risk factor (85%) and others include drug induced (8%), and gastrointestinal causes (24%). Hematological manifestations were found in 100% of cases, Anemia was found in 100% of cases and pancytopenia was found in 80% of cases.

10. Clinical Analysis of Severe Anaemia

PK Dhawan
Military Hospital, Agra Cantt, UP 282001.

Fifty two cases of severe anaemia with Hb < 5.0 gm% with no overt cause, were analysed at a zonal hospital in UP.

Presentation was with easy fatiguability in 24 (46%), dyspnea on accustomed exertion in 14 (27%), giddiness in 5 (9.5%) cases while 9 (17.5%) cases esp females were rather asymptomatic.

Females out numbered males (32:20) esp in maximally involved age group of 15-25 years, while a second peak was noted in the elderly (> 65 yrs) where males and females were similarly affected.

Normocytic and microcytic hematological picture was prominent in the elderly, while megaloblastic and hemolytic type was marked in the younger population. G6PD deficiency was noted in 7 (15%) cases on screening for hemolysis. Malaria and leukemia were noted in 2 cases each.

Nutritional factors remain an important cause in the elderly while hemolytic anaemia esp. G6PD deficiency needs to be looked for in the younger population with its preventable aspect.

11. A Case Report : Multicentric Castleman Disease Converted into Non-Hodgkin Lymphoma and Its Treatment with Chop Regime

R Dewan, K Kuldeep, S Garg, T Singh, P Gupta, M Sharma, R Kochhar
Department of Medicine, Maulana Azad Medical College, New Delhi.

Background : Castleman disease, a rare condition of unknown cause consisting of a massive proliferation of lymphoid tissue. Precise incidence is not known. There is 20% to 30% conversion into NHL, reported in multicentric form.

A 42 yrs old lady presented 4 years back with cervical and inguinal lymphadenopathy without hepatosplenomegaly. The lymph node biopsy revealed Castleman’s disease, hyaline vascular type. The patient was lost to follow up and did not receive any treatment. After 4 yrs she again presented with multiple cervical, axillary, inguinal lymphadenopathy. There is history of abdominal distention, constitutional symptoms like mild to moderate grade fever, anorexia, weight loss, malaise for last three months. On examination vital were stable. There were Pallor, bilateral pitting edema, nontender hepatospleenomegaly, generalized lymphadenopathy involving bilateral cervical (anterior and posterior triangle), pre and post auricular, axially, inguinal lymph node, 2 to 5 cms in size, multiple, discrete, rubbery in consistency, not fixed to underlying structure, overlying skin were normal.

Investigations revealed severe anemia (4 mg/dl), macrocytes and segmented neutrophills in peripheral smear. HIV ELISA, PCR for MTB, VDRL were negative, Widening of mediastinum in the chest X-ray, lymph nodes along aorta caval, along iliac vessels, mesentery and in the pelvis, hepatosplenomegaly in USG Abd. CECT chest and abdomen shows mediastial and abdominal lymphadenopathy along with hepatosplenomegaly. MRI neck was suggestive of cervical Lymphadenopathy, which shows white was appearance on contrast enhancement suggestive of highly vascular lymph node. Repeat biopsy shows T-cell rich B-cell lymphoma (cd20+) Tcell rich NHL. Bone marrow aspiration and biopsy suggestive of lymphomatous involvement of bone marrow. Pt was started on CHOP regime. During the chemotherapy pt developed neutropenia, pneumonia, PARANEOPLASTIC PEMPHIGUS VULGARIS, candidiasi and severe proximal myopathy. After receiving three course of chemotherapy all the lymph nodes, hepatosplenomegaly, constitutional symptoms disappeared, started gaining weight and achieved normal appetite.

12. A Phase II Study of Low Dose Thalidomide and Dexamethasone in Previously Untreated Multiple Myeloma

B Thomas, K Pavithran, N Prasad, M Unni, K Kishore, A Majeed, TS Ganesan
Cancer Institute, Amrita Institute of Medical Sciences, Kochi.

Objective : To evaluate the efficacy and safety of low dose Thalidomide and Dexamethasone in previously untreated patients with Multiple Myeloma.

Methods : We analysed the records of 25 patients (M/F:18/7), median age was 57.8 years (range 37-74) with previously untreated symptomatic myeloma who were recruited between October 2005 and December 2006. The Salmon Durie stage of patients were I (16), II (7), IIIA (4) and IIIB (8). Patients were treated with Thalidomide 100 mg daily and Dexamethasone (40 mg daily x 4 days) once monthly for 6 months. All patients included in the analysis received 6 months of therapy. All patients were investigated with protein electrophoresis, skeletal survey and bone marrow aspiration and biopsy. In addition, β2-microglobulin (14/ 25) and immunoglobulin electrophoresis (15/25) were done in a subset. Response was determined by as per the EBMT criteria (CR defined as Plasma cells < 5% in bone marrow).

Results : Thalidomide was tolerated in all patients. The main side effects were peripheral neuropathy (4/25) (all grade 1), pedal edema (6/25), constipation (4/25) and sedation in (2/25). In addition, one patient had pneumonia and another had neutropenia, which required hospitalisation. There was no evidence of deep vein thrombosis. The response was CR in (15/25), S.D. (2/25), P.D. (3/25). In addition 5/25 had a PR (plasma cells < 10%). Those in CR received either Thalidomide (50 mg) alone or Thalidomide (50 mg) and Dexamethasone (10 mgX4 days) or no treatment. 2/15 patients who achieved CR and were not on any treatment relapsed within 6 months and died of myeloma.

Conclusion : The above results show that Thalidomide and Dexamethasone at a lower dose is a safe and effective regimen in previously untreated Multiple Myeloma. The complete response (60%) rate in Indian patients is significantly higher than that reported in the literature (< 10%). The mechanism of the increased response to Thalidomide needs further evaluation in Indian patients.

13. Prospective Study of Percutaneous Endoscopic Gastrostomy (PEG) in Head and Neck Cancer Patients Our Experience

SS Chatni, SC Shilpa*, Viswapriya, S Sadavisan, M Geetha, I Siyad, V Sooraj, G Rajesh, S Hussain, P Gaurav, S Iyer*, MA Kuriakose*, P Nair, VA Narayanan, V Balakrishnan
Digestive Disease Institute and Head and Neck Surgical Oncology*, Amrita Institute of Medical Sciences and Research Centre, Amrita Lane, Elamakkara, Cochin 682 026.

Objective : Patients with head and neck cancer often require an extraora route for nutritional support after tumour resection and while undergoing adjuvant therapy because of altered pharyngeal anatomy and impaired deglutition. These patients are commonly nutritionally depleted and cannot meet their caloric needs without nutritional support. The present prospective study was undertaken to evaluate the indications and complications of percutaneous endoscopic gastrostomy in head and neck cancer patients.

Material and Methods : A prospective analysis of 50 patients with primary head and neck carcinomas who had PEG tubes placed at the Digestive Diseases Institute, Amrita Institute of Medical Sciences, Kochi, Kerala from August 2006 to June 2007 was done. The primary outcome was nutrition status. The secondary outcomes were complications and duration of PEG tube feeds. Endpoints to the study were elective removal of PEG tube. The variables, serum albumin, hemoglobin, BMI were recorded at pre PEG, 2 weeks after PEG, 2 months after PEG and at removal of PEG tube.

Results : Fourty two patients were male (84%), and the median age of the patients was 57 years (Range 32-83). Time of PEG tube placement was: Pre Chemoradiotherapy (25 patients), Pre Radiotherapy (24 patients), Palliative intent (1 patient). The tumour location was as follows. Oral cavity 24 patients, Oropharynx 11 patients, Nasopharynx 6 patients, Larynx 4 patients, Hypopharynx 4 patients and Maxilla in 1 patient. PEG feeds were started 24 hours after the procedure. Pull technique was used in 46 patients and push technique was used in 4 patients. All patients received antibiotic, IV Cefazoline 2 grams, half an hour before the procedure. The duration of PEG Tube feeding ranged from 37-193 days. The minor complications were pus at PEG site in 8 patients, pain at PEG site in 3 patients, hematoma at PEG site in 1 patient and respiratory stridor in 1 patient. Success of PEG tube insertion was achieved in all patients. There were no deaths related to PEG procedure.

Conclusion : PEG is a good choice for long-term enteral feeding in head and neck cancer patients due to its low complication rate and easy handling. The use of PEG in patients with oral tumours at our institution was found to be effective in maintaining adequate nutrition, as assessed by weight and BMI, during recovery and convalescence.

14. Pleotropic Anti-Inflammatory Effects of Atorvastatin in Type 2 Diabetes Mellitus and Syndrome - X

S Ghosh, BK Barik, RL Kumar, P Das
VSS Medical College, Burla

Aims and Objectives : To study the effect of low dose Atorvastatin on inflammation, insulin resistance and lipid profile by measuring C-Reactive Protein (CRP)-(Biochemical marker of inflammation) - in patients with type-2 Diabetes Mellitus (DM) and Syndrome-X and reduction in incidence of cardiovascular events.

Material and Methods : In this study 50 cases of type 2 DM with or without syndrome X were taken (according to ADA and NECP ATP III guidelines) an all patients were assigned to receive Atorvastatin 10 mg/day. Baseline blood sugar, lipid profile were measured by spectrophotometric assay and serum CRP was measured by Turbi latex analyzer and repeated after one month and six month of therapy. 30 patients of age and sex matched controls were taken who had no history of DM and Syndrome-X and their CRP levels were estimated.

Observation : Four weeks of treatment with Atorvastatin improved the lipid profile (DL-C and TGs and -HDL-C), improved glycemic control and reduction of both systolic and diastolic blood pressure. Moreover Atorvastatin markedly reduced the serum CRP (mean from 24 ± 16 to 8 ± 4) after 4 weeks of treatment which were not correlated with that of reduction in LDL-C (mean 164 ± 36 to 86 ± 12). The level of CRP and other beneficial extra-lipid effects remained decreased after six month of treatment and so were the overall cardiovascular events.

Conclusion : The study results suggest that Atorvastatin has beneficial effects on inflammation, lipid profile blood pressure and better glycemic control in type 2 DM and Syndrome-X. The reductions in inflammation and extra-lipid effects were not attributed to the lipid lowering effects of the statin, indicating that Atorvastatin has pleotropic effect.

15. Antiatherogenic Properties of Ploglitazone in Type-2 Diabetes Mellitus

S Baul, G Agarwal, PK Padhi, BK Barik
Department of General Medicine, VSS Medical College, Burla.

Aim and Objective : Type - 2 DM have two to four fold risk of CAD and associated with atherosclerosis, dyslipidemia and hypertension. Role of inflammation in Atherosclerosis is established. The study was taken with aim to show the antiatherogenic effect of Pioglitazone by decreasing serum CRP, the inflammatory marker and to establish the pleotropic effect i.e. antidiabetic, hypolipidemic and antiatherogenic effect. Material and Methods : As per ADA 2006 guidelines 80 patients (56 males, 24 females) of Type - 2 DM were taken for study. Twenty control cases were included in this study. Applying exclusion criteria and conditions for raised CRP cases were excluded. All cases were subjected to detail clinical and laboratory study including HbA1c (Ion Exchange Method), lipid profile (Enzymatic Method) and serum CRP (Immunoturbimetric Method). The patients were advised Piglitazone (30 mg/day) along with their previous OHA and Statin or antihypertensive drugs. The parameters were repeated after 3 months of Pioglitazone therapy.

Observation : In the present study 64 cases were of Metabolic Syndrome as per ATP III guidelines. After Pioglitazone the mean FBS 168.6 ± 14.80 to 160.4 6.0 mg/dl. So also HbA1c from 8.4 ± 0.78 to 7.4 ± 0.68. Serum TG reduced from 168.5 ± 6.4 to 160.4 ± 6.0 mg/dl. The levels of LDL-C and total cholesterol also decreased. HDL-C increased from 35.7 ± 3.2 to 38.1 ± 3.2 mg/dl. The serum CRP was reduced from 3.4 ± 0.63 to 2.4 ± 0.20 mg/L which was statistically significant. There was no change in liver enzymes and serum bilirubin levels indicating to hepatotoxicity.

Conclusion : Type - 2 DM manifests like hyperglycaemia, dyslipidemia, obesity, hypertension, prothrombotic and procoagulant activities. Pioglitazone, a Thiazolidinedione is a PPAR-γ agonist, acts as insulin sensitizer in liver, adipocytes, peripheral tissue. Its hypolipidemic effect reduces TG, increases HDL and induces favorable change in LDL-C. The present study revealed significant reduction in CRP independent of its hypoglycemic and hypolipidemic effect. Thus plioglitazone have pleoropic antiatherogenic and anti-inflammatory effect providing cardiovascular advantages.

16. Body Fat Percentage and Prevalence of Diabetes in First Degree Relatives of Type 2 Diabetics

BN Mahanta, Tulika Goswami Mahanta
Assam Medical College, Dibrugarh - 786001. Assam

Aims and Objectives : To measure total body fat percentage of persons with evidence family history of diabetes mellitus; to assess the BMI and other risk factors of persons at risk of developing diabetes mellitus; and to compare the body fat percentage between first degree relatives of diabetics and nondiabetic patients.

Material and Methods : Total 140 subjects first degree relatives of diabetic patients and similar no of age and sex matched control were selected from first degree relatives of non diabetic patients. Detailed clinical, systematic, anthropometric evaluation and calculation of BMI and blood sugar and other relevant laboratory investigations were done. Body fat percentages were calculated using bioimpedance method, using fat monitor.

Results : Average percentage of body fat was 32.52% subjects were overweight (BMI 25-<30). It has been proved statistically that hypertension was 4.5 times higher in cases than control group (95% C.I-2.57-7.91, p < 0.005). In case of obesity the difference between case and control was not significant (OR-2.09, 95% C.I0.61-
7.24, P > 0.05). BMI was 4 times higher in cases than control groups (95% C.I.-2.49-7.20, P < 0.001). During the study the newly detected DM was significantly higher amongst cases than control (OR-25.52, 95% C.I.-15.42-42.59, p < 0.001). Body fat percentage was 3.88 times higher in cases than control group. The difference of body fat percentage was statistically significant (95%C.I.-2.35-6.43, p < 0.001).

Conclusion : Body fat percentage monitoring is a useful tool for assessing the potential diabetics, particularly for high risk screening and it may prove as an important tool for evidence based monitoring of life style modification approaches for health promotion.

17. Clinical Profile and Complications in Newly Detected Type 2 Diabetics (Age group 20-60 years)

KP Ranganayakulu, BC Pruthvi, R Subramanian, JB Prakash, NR Rau
Kasturba Medical College, Manipal 576 104.

WHO report shows that India tops the world with largest number of diabetics nearly 33 million, we Indians have a genetic phenotype characterised by low BMI with high upper body adiposity, high body fat percentage and high level of insulin resistance. There is very little data regarding the prevalence of diabetes and its complications in Indian population. This study is designed to study the complication profile of type 2 diabetics between 20-60 years at diagnosis and compare this profile with studies done 5 and 10 years back.

This is a prospective study done in KMC, Manipal and study population being both sexes within age group > 20- < 60 years and diagnosed to have diabetes at present admission or within last 3 months by ADA criteria.

Preliminary studies done revealed 60% of the patients between age groups 40-49, approximately 25% below 40 years of age. A positive family history in 1/3 of the patients. Retinopathy seen in 10%, Nephropathy and Neuropathy in approximately 6% and macro vascular complications in approximately 6%.

Conclusion : Incidental Diabetes on evaluation during hospital admission is much more common than those presenting with symptoms of hyperglycemia and significant proportion had micro and macro vascular complications on diagnosis. Approximately 25% of patients were below 40 years, showing the need for blood sugar level estimation even in younger age groups.

18. Clinical Profile of Newly Detected Diabetes in Elderly

G Chawla, NR Rau, JR Prakash, R Subramanian, BC Pruthvi
Kasturba Medical College, Manipal 576 104.

Type 2 diabetes mellitus is a growing problem among the elderly people of India. Diagnosis and treatment of the older population have unique challenges. Due to physiologic changes associated with aging, the elderly patient with diabetes may not present with classic symptoms. Aim of my study was to determine the clinical and complication profile of newly detected diabetes in elderly (above 60 years) and to know the prevalence of obesity in them. Study is done in KMC Manipal and TMA Pai Hospital Udupi where all patients of both sexes more than 60 years detected to have diabetes for the first time at presentation or during past 3 months by ADA criteria are included in the study population. They are enquired about complaints, examined and appropriately investigated.

Preliminary studies have shown that maximum age at presentation was 82 years and minimum age being 60 years with 70% having associated obesity. 25% have IHD and 5% having CVA. Nephropathy seen in 10% of cases with 5% having neuropathy and retinopathy. Family history is present in 40% of cases. None of them had classic symptoms of polyuria polydipsia and polyphagia at time of presentation and 5% presented with DKA 20% had dyslipidemia.

Conclusion : High prevalence of obesity in newly detected diabetes in elderly. Classic symptoms of diabetes are absent. Macrovascular complications are more common than microvascular complication. Acute complications can also be seen at presentation in newly detected diabetes in elderly.

19. Study of Serum Magnesium Level (Ionic) in Diabetes (Type-II) and Impaired Fasting Glucose Patients

A Singh*, A Chandra, Mam Chandra, R Mishra, V Atam
*Department of Medicine, CSM Medical University, Lucknow.

Objective : Study of serum magnesium level (ionic) in diabetes (type-II) and impaired fasting glucose patients.

Method : Three groups were studied:

1. Known case of type-II diabetes mellitus.
2. Persons with impaired fasting glucose selected from positive family history of diabetes mellitus, history of gestational diabetes, hypertension, dyslipidemia, obese persons.
3. Persons with no history of diabetes mellitus or other risk factors.

The clinical status, presence of microvascular and macrovascular disease and early marker of atherosclerosis and relationship with serum magnesium has been studied.

Result : Preliminary results all groups have serum magnesium level within normal range but in diabetics and impaired fasting glucose patients it was towards lower normal side.

Full study with analysed details will be completed by APICON’2008.

20. Hypoglycaemia in Type II Diabetes Mellitus

RS Khot, JP Gawande,
MM Paithankar Govt. Medical College, Nagpur.

Hypoglycaemia is an important therapeutic complication and also a major deterrent for achieving intensive diabetes control. Aim : To study the prevalence clinical profile and risk factors for hypoglycaemia in Type II DM.

Method : In this cross sectional study 300 patients of Type II DM were screened for hypoglycaemia using a questionnaire and confirmation by blood sugar levels whenever possible. 72 patients having hypoglycaemia were classified as mild (symptoms and Random blood sugar (RBS) < 72 mg/dl) and severe (Neuroglycopenia and RBS < 60 mg/dl). All patients were evaluated for risk factors like age, sex, smoking, alcoholism, Body mass index, waist hip ratio, educational status, socio-economic status, knowledge about DM, its complications, Treatment and glycaemic control by specially designed questionnaires and appropriate laboratory investigations. 228 patients without hypoglycaemia were taken as controls. Univariate and multivariate analysis was done.

Results : Prevalence of hypoglycaemia was 24% (n=27). 50 (69.4%) had mild hypoglycaemia and 22 (30.6%) had severe hypoglycaemia. Sweating in 55.5% and giddiness in 47.2% were common symptoms of mild hypoglycaemia where as coma was the presenting symptom in all cases of severe hypoglycaemia. 75% of the hypoglycaemic episodes occurred during day and 58.3% had no identifiable precipitating factor. 36.1% episodes were related to missed meals and 12.5% had multiple episodes of hypoglycaemia.

On multivariate analysis Alcoholism, lower educational status, longer duration of DM, lower BMI and WHR, and Insulin therapy alone and in combination were significant risk factors associated with hypoglycaemia (p < 0.05). Hypoglycaemia was more common in cases with fair glycaemic control than poor or good glycaemic control.
Conclusion : There is a high prevalence of hypoglycaemia i.e. 24% and is associated with some modifiable risk factors like alcoholism, lower education, knowledge and awareness. Hence episodes of hypoglycaemic can be minimized and will not be a limiting factor for good control of DM.

21. Emphysematous Pyelonephritis A Report of Two Cases

S Verma, Pushpa Yadav, D Srivastava, SC Sharma
Dr. Ram Mandhar Lohia Hospital, New Delhi.

Emphysematous pyelonephritis is a life threatening acute necrotising parenchymal and perirenal infection caused by gas forming pathogens, most commonly seen in diabetics (90%), or secondary to obstruction of urinary tract by calculi, neoplasm, stricture or papillary necrosis with significant renal function impairment. It is a rare entity. We report two diabetic patients with emphysematous pyelonephritis.

Case 1 : A 60 years-old female, diabetic for 15 years, presented with high grade fever, burning micturition, and abdominal pain of 15 days duration. Abdominal examination revealed a lump in right lumbar region 15 x 12 cm, tender firm and ballotable. Urine showed numerous puscells, 1+album and positive ketones. Urine culture showed a mixed growth of E. coli and proteus organisms. Her kidney and liver function were normal. Blood sugar was 400 mg%. Ultrasound of abdomen showed a right renal mass with hydronephrosis. CECT abdomen was characteristic of emphysematous pyelonephritis right kidney. Patient was managed with parenteral antibiotics, insulin. A right sided nephrectomy had to be done as it did not respond to conservative measures, following which she had a good recovery. On follow up, her diabetic state is under good control and renal function are stable.

Case 2 : A 62-year-old male diabetic for 3 years, admitted with high grade fever, abdominal pain and vomiting fo 4 days duration and altered sensorium of 1 day. He had altered sensorium and was febrile. BP 120/80 mmHg with mild pedal oedema. On abdominal examination, extensive crepitus was elicited over left hypchondrium and an ill defined tender swelling was palpable in left lumbar region. Urine culture showed heavy growth of E. coli organisms. Blood urea was 368 mg%, serum creatinine 7.1 mg% and Blood sugar was more than 400 mg%. NCCT Head was normal. Ultrasound abdomen showed left renal mass with hydronephrosis. CECT abdomen showed normal right kidney and enlarged left kidney with extensive gas collection in the parenchyma nd retroperitoneum. Patient was managed with parenteral antibiotics and regular insulin. Since the patient continued to be toxic and febrile the urologist was consulted and left sided nephrectomy was carried out. But the patient continued to be grave and expired after 24 hrs. of surgery.

Discussion : There have been few case reports of emphysematous pyelonephritis in literature. More than 90% of the reported case have occurred in diabetic adults. The infecting organisms usually cansist of mixed flora including Escherichia coli (68%), klebsiella pneumonia (9%), proteus mirabilis, pseudomonas, enterobacter, candida and rarely clostridia species. It is a surgical emergency involving aggressive antibiotic therapy, drainage procedures to relieve obstruction and prompt nephrectomy in left threatening situations. The mortality remains high even with combined medical and surgical management. The second case also high lights the importance of looking for clinical signs, since a precise diagnosis could be made at the bed side due to the presence of extensive surgical emphysema.

22. Profile of Individuals with Type 2 Diabetes Mellitus : Results from A Community Survey.

R Arun, VR Kutty, G Vijayakumar
Medical Trust Hospital and Diabetes Care Centre, Pathanamthitta, 689 503 Kerala.

Background : Among those with Type 2 diabetes mellitus (DM) there is greater probability of coexistence of other noncommunicable diseases (NCDs) like hypertension, dyslipidemia and obesity due to common predisposing factors. Such coexistence implies enhanced risks of complications of DM. Hence a holistic approach is warranted in diabetes care. In India, there exists little literature from community-based studies on the management of DM and the concomitant NCDs, and their control.

Objective : To understand the management and control of DM, and to assess the prevalence and control of hypertension, hypercholesterolemia and obesity among individuals having DM in one of the Panchayat Wards in Venmony Panchayat, Chengannur Taluk, Kerala, India.

Methodology# : As part of a cross-sectional survey among usual adult residents (N=995) of a Ward, overnight fasting blood samples were collected from all consented participants (response rate: 86.4%) to measure fasting plasma glucose (FPG) and total serum cholesterol (SCHOL). Through quantitative research methodology, data were collected using a pre-tested questionnaire. Standard procedures were followed for anthropometric measurements. Data were analysed using appropriate statistical software. The present analysis is based on data from 79 individuals, i.e. sample size = 79 (men:40, women:39) in the Ward, who self-reported as having DM.

Results : Of the 79 individuals who reported as having DM, 97.5 percent were following some form of treatment to control DM. Only 45.6 percent practicing life style modification (LSM), either alone or in combination with other treatment modalities. Nearly 66 percent had their FPG controlled (FPG ≤ 130 mg/dL). Among those who reported as having DM, the prevalence of hypertension (SBP: ≥ 140 and/or DBP: ≥ 90 or on antihypertensive) was 62 percent; the prevalence of borderline high cholesterol (SCHOL: 200-239 mg/dL) was 44 percent and of high cholesterol (SCHOL: ≥ 240 mg/dL) was 9 percent; the prevalence of overweight (BMI:23.00-24.99) was 25 percent and of obesity (BMI: ≥ 25.00) was 42 percent. Forty four percent (35/79) self-reported as having hypertension, of which 85 percent (30/35) were on antihypertensive, of which only 16 percent (5/30) had their blood pressure in desirable level, i.e. BP: < 130/80. Sixteen percent (13/ 79) self-reported as having hypercholesterolemia, of which 46 percent (6/13) were on hypolipidemic drugs, of which 66 percent (4/6) had their serum cholesterol in the desirable level, i.e. SCHOL: < 170 mg/dl.

Conclusions : A high proportion of those having DM have coexisting NCDs. The treatment and control of those NCDs and even more so of DM are far low, which points towards inadquacies in diabetes care.

#The present analysis is based on data from the authors’ original research study titled ‘Prevalence and correlates of Type 2 diabetes mellitus in Kerala’ conducted among usual adult residents of two Panchayat Wards in Venmony Panchayat, Chengannur Taluk, Kerala, India. The primary study had 995 eligible participants from each Ward.

23. Status Epilepticus Due to HSV Lasting for 60 Days Unresponsive to Conventional therapy - A Case Report

R Ravi, S Seshadri, V Pandit, V Rohith
Kasturba Medical College, Manipal.

An eighteen year old male presented with history of two episodes of generalized tonic clonic seizures. He had no previous history or family history of seizures. On examination, he was in altered sensorium. There were no signs of raised intracranial tension, meningitis or focal neurological deficit. Routine investigations did not reveal any metabolic cause for seizures. CSF analysis was normal. CT Scan brain showed meningeal enhancement with exudates in the tentorial region and falx cerebri suggestive of meningitis. MRI showed evidence of post-ictal changes. EEG showed discharges of two to three Hz with slow wave background. Hence on a working diagnosis of Herpes Simplex encephalitis, the patient was treated with I/V acyclovir and phenytoin. As seizures persisted (upto 30 seizures per day), he was treated with a cocktail of phenobarbital, midazolam, sodium valproate, carbemazepine, thiopentone, magnesium sulphate, gabapentin, lamotrigine and clonazepam and given a continuous infusion of propofol, after which seizure frequency decreased. Repeat MRI done was suggestive of hypoxic changes. The patient recovered completely with no residual neurological deficit. On follow up, maintenance anti-epileptics were continued and there were no further seizures.

24. Sturge Weber Syndrome Type I with Spontaneous Haemopneumothorax

GN Gupta, SC Tewari, MB Chandurkar, SS Kadam
Rural Medical College, Pravara Rural University, Loni, Ahmednagar 413 736.

A 19 year old male presented with H/O a large portwine patch over left forehead, eyelids, cheek and upper lip since birth, seizures since age of 1 year (on therapy) and sudden onset breathlessness and cough of 8 days duration. With history, clinically and obvious neurocutaneous markers it looked to be a case of Sturge Weber Syndrome. However, he had a right sided haemopneumothorax with no clear evidence of any lesions infective or otherwise in lungs or pleura even on CT scan which showed haemopneumothorax. Eye changes noted were Buphthalmos and congenital glaucoma. On detailed analysis of pleural fluid including culture, no infection or other pathology was detectable and thus a diagnosis of spontaneous haemopneumothorax was entertained.

Since haemangiomatous malformations are reported in Sturge Weber syndrome in various organs including liver, ocular, cranial and dermatological possibility of such malformations on surface of lung breaking down and producing a haemopneumothorax was considered. Confirmation of this could have been done only with pulmonary angiography for which facility and patient’s acceptance was not there, hence could not be confirmed. Patient improved with ICD drainage and no residual fluid or pleural thickening was detected. Case is presented for its unique features.

25. Antiepileptic Hypersensitivity Syndrome in A Case of Refractory Seizures

CN Vijesh, S Kavitha, BA Shastry, S Raghu
Kasturba Medical College, Manipal.

Antiepileptic hypersensitivity syndrome is a serious idiosyncratic, non-dose-related adverse reaction reported to occur with phenytoin, phenobarbitone, carbamazepine, primidone and lamotrigine. The reaction usually develops 1 to 12 weeks after initiation of therapy with one of the above agents and is recognized by the classic triad of fever, rash, and internal organ involvement.

Pushpa, 17 yrs, female, no pre-morbid illness, diagnosed 2 months back with seizure disorder and advised phenytoin, sodium valproate and clonazepam was brought to the casualty with Status Epilepticus. Historically seizures were Complex Partial seizures with secondary generalisation. No significant family history. On examination vitals were stable, patient was in altered sensorium, plantars were B/L extensor. Metabolic work up and other lab parameters were normal. MRI Brain revealed B/L mesial temporal lobe sclerosis. The seizures were controlled with Phenobarbitone, Phenytoin, and Sodium Valproate initially and the patient was seizure free for one week (except for one episode). Meanwhile, patient developed low grade fever, skin and mucosal lesions s/o Stevens-Johnson syndrome. Phenytoin, phenobarbitone, and carbamazepine were stopped and valproate was continued. Patient was treated with Dexona and Prednisolone. The skin lesions resolved slowly. However, the seizures recurred with increasing frequency. T. Levitiracetam and T. Clobazam were added. Patient started showing significant clinical improvement (except for occasional partial seizures).

Newer antiepileptic medications such as T. Levitiracetam have a better side effect profile and can be combined with first line antiepileptics for optimum control so that severe hypersensitivity reactions can be significantly brought down.

26. Headache - Study of 100 Patients in a Tertiary Referral Centre - Pattern, Awareness and Role of Education

R Pazhani, A Kalanidhi, NTR Balasubramanian, RP Rajesh, M Swarna
SR Hqrs. Hospital, Chennai

Objective : To study the pattern of Headache, patients awareness about their headache and to highlight the role of educating patients about their illness, in 100 patients attending Neurology clinic of Southern Railway Headquarters Hospital from 1-6-2007.

Methodology : Cross sectional - observational study of consecutive 100 patients attending the clinic with headache. Patients were interviewed, with reference to the insight of their illness, the specialities of medicine they have attended before attending neurology clinic. The investigations and treatments they have undergone with emphasis on the efficacy and adverse effects of the same are also taken note. Patients are followed up for the improvement in their symptoms after the diagnosis, treatment and education regarding their illness given in the clinic.

Summary : Although 90% of headaches have neurological basis, patients frequently attend neurology after attending a number of other specialties. They also try other alternative forms of medicine. This causes a huge loss of resources like time, money, and manpower to the patient and the nation. Physical discomfort and anxiety is caused due to lack of focus in educating the patients about their illness. Depression is found more often in headache patients.

Conclusion : The pattern of headache observed to be compared with the prevalence rates of various types of headaches in the literature. Study results will throw light on the knowledge, attitude and practice of patients with headache. Results will evaluate the impact of educating the patients in the outcome with respect to the symptom alleviation and improvement in the quality of life with headache.

27. A Rare Case Report-Lafora Disease

N Jothimurugan, Ramasamy, Sathyababu, Lavanya
Stanley Medical College, Chennai 600 001.

16 yr old fathima came with the complaints of seizures-3 years.

Frequent falls, forgetfulness, jerking of limbs - 2 years.

Examination of CNS system shows memory impairment, cognitive decline, myoclonus present. MMSE score revealed 16/ 30. Investigations revealed bilateral slow waves of theta and Delta frequency in EEG. Skin biopsy from axilla showed PAS positive focal accumulation of polyglucosan bodies in the apocrine glands-suggestive of lafora bodies.

This case is presented because of its rarity.

28. A Cross-Sectional Study of Stroke in the Geriatric Age Group in an Urban Slum Area, Using Modified Who Screening Protocol

M Amita, Pandit, U Sundar, S Adwani
Department of Neuromedicine/PSM, LTMMCH, Sion, Mumbai 22.

Background and Purpose : Stoke is a leading cause of mortality and morbidity, both in developed and developing countries. Information on stroke prevalence/incidence is inadequate in India.

Methods : Study participants were selected by systematic random sampling. A trained interviewer performed face-to-face interviews with subjects using a modified version of the World Health Organisation screening protocol for neurological diseases, with added questions to screen specifically for stroke. Potential stroke patients underwent a clinical evaluation to confirm or exclude stroke. Medical records review and careful interviews with relatives were performed for those unavailable for clinical evaluation. Risk factors and socio-demographic factor associated with stroke were assessed.

Results : The study involved 1726 participants: 730 men, 996 women, age range 60 to 105 years. Participation rate was 98.23%. Sixty-six were diagnosed to have a stroke, yielding a crude prevalence rate of 3.82% (95% CI, 2.92 to 4.72). Prevalence rates rose with age (P < 0.001 for trend) and were higher among men compared with women, 5.21% (95% CI, 3.60 to 6.82) versus 2.82% (95% CI, 1.78 to 3.84), P < 0.01. Examination of 32 screening negative individuals disclosed no further stroke patients, yielding the screening instrument 100% sensitivity, 99.4% specificity, 86.8% predictive value of a positive test and 100% predictive value of a negative test. A subsection (23 stroke survivors) could be confirmed on CT plates (82.6% infarcts and 13% hemorrhage). 81.81% stroke survivors had confirmed hypertension, 19.7% had diabetes mellitus, 18.2% had IHD, 3% had RHD, 33% reported tobacco abuse, 39.4% reported physical inactiveness. Logistic Regression analysis showed hypertension (OR 34.59) and physical inactivity (OR 5.76) to be significant risk factors.

Conclusions : The prevalence rate of stroke in geriatrics is comparable with rates observed elsewhere in India and other developing countries. The screening instrument developed in this study may be used to further research on stroke as its sensitivity, specificity, positive and negative predictive values are comparable with or higher than those of similar studies.

29. Gaze Palsies Due to Central Brain Stem Lesions - 2 Case Reports

M Kushe, S Uma, S Swati, R Prashanth, A Sikander
LTMMC and LTMGH, Sion, Mumbai - 22.

Introduction : Pattern of gaze palsies in central lesions are distinctive and peculiar to the site of lesion, we describe 2 cases of gaze/ocular nerve palsy where the distinctive clinical features pointed to the localisation.

Case Report 1 : 51 yr/m/Non compliant on AKT for pulmonary TB, presented with acute binocular diplopia and crossed Hemiplegia. Clinical examination revealed Bilateral up gaze palsy, bilateral ptosis (picture), (rt) blephatospasm, Left inferior rectus+ superior oblique palsy + Right Hemiplegia. Clinical localization was made to Left side mid brain 3rd nerve nucleus + crus cerebri involvement. A ring enhancing left sided mid brain granuloma s/o TB was seen on MRI, confirmed on MR spectroscope.

Case 2 : 35 yr. old Lady presented with acute onset altered sensorium. Clinical examination revealed generalized apathy, the only localizing feature was Bilateral Upgaze palsy. A possibility of thalamic involvement was considered contrast enhanced ct scan was normal. MRI showed Bithalamic signal abnormality. MR Angiography showing occlusion of perforating thalamic feeder vessels.

Learning points: 1. Symmetrical ptosis is a sign of caudal midline 3rd Nerve nucleus involvement. The original description of Benedicts Syndrome includes Nuclear palsy with contralateral Hemiplegia. 2. Paramedian Thalamic Infarction (due to occlusion of paramedian and subthalamic arteries) result in classic triad of drowsiness, memory loss and vertical gaze dysfunction.

Ref : thalamic Syndrome (pg 1208), Brain-stem syndrome (pg 2108) principles of neurology by Walter Bradley.

30. Ophthaloplegia, Blindness and Acute Quadriparesis – A Rare Presentation of Intracranial Cerebral Venous Thrombosis (CVT)

U Sundar, S Chavan, T Karandikar, S Adwani, ME Yeolekar
Department of Medicine, LTMMC and LTMMH, Sion, Mumbai.

Background : CVT has wide range and severity of clinical presentations, we report a rare case presentation of quadriparesis in a case of CVT.

Case Report : A 58 year old male presented with subacute onset binocular painless loss of vision with inability to move eyes in any direction and progressive limb weakness. He had preserved cognition, was alert and oriented, had bilateral pappiloedema with vision reduced to hand movements, there was complete ophthalmoplegia and diffuse areflexia with proximal weakness in the limbs (MRC-3+).

Possibilities considered were midbrain infarction and polyradiculoneuropathy with ophthalmoplegia due to raised ICT. MRI Brain/Spinal cord were normal, MR venogram showed extensive superior saggital, transverse and sigmoid sinus thrombosis. ANA, Procoagulant work up, sickling test were negative. VEP showed positivity at > 180 ms left eye, no response in right eye. NCV showed e/o polyradiculopathy (mixed). CSF pressure was above 400 mm manometer mark and analysis was normal. Lumboperitoneal shunting and anticoagulation resolved ophthalmoparesis and vision improved partially.

Learning Points : 1) Markedly raised intracranial pressure due to CVT produces potentially a reversible cranial nerve/ polyradicular dysfunction due to enlarged subarachnoid spaces distending nerve roots/additionally by ischaemia. 2) Early lumboperitoneal shunting in this situation averts irreversible visual loss.

31. A Clinical Study of Complications in Acute Stroke

RK Kotakey, De Arijit, AK Azad
Assam Medical College and Hospital, Dibrugarh.

Aims and Objectives : To examine the frequency and specific types of medical complications that occurs among patients with acute stroke.

Material and Methods : A total of 63 patients presenting within 7 days of stroke onset and admitted for more than 3 days in hospital were prospectively screened for the appearance of some common predefined complications of acute stroke as inpatients in Assam Medical College and Hospital, Dibrugarh during a period of 1 year.

Results and Observations : Out of the 63 cases studied, 38 cases (60.3%) had suffered from at least one complication during their hospital stay. The most common complications observed were bed sore and urinary tract infection (23.8%). They were followed by musculoskeletal pain 22.2%, chest infection 17.4%, seizure 14.3% and DVT in 1.6% of the cases.

Conclusion : The development of complications during an acute attack of stroke has a significant impact on the outcome of the illness and even in the cost of management by increasing the risk of mortality and adding to the morbidity also. This raises the possibility that rigorous attention in the prevention and early treatment of complications could improve the outcome of stroke patients. So far as our knowledge goes, the present study is the first of its kind that has prospectively studied the incidence and the risk factors for medical complications in acute stroke from this part of Upper Assam.

32. Usefulness of Mannitol in Spontaneous Intracerebral Hemorrhage (ICH) Patients

V Agrawal, TP Singh
SN Medical College, Agra.

Objective : To study the usefulness of Mannitol in spontaneous intracerebral hemorrhage (ICH) Patients.

Methods : 78 CT proven supratentorial ICH patients within 6 days of ictus were randomized into study and control groups. The study group received Mannitol 20%, 100 ml every 4 hrs for 5 days, tapered in the next 2 days. The control group received saline infusion. Primary end point was 1 month. Mortality and secondary end point functional disability at 3 months assessed by Barthel index score.

Result : There were 40 patients in study and 38 in control group. The study and control groups were evenly matched regarding age. Glasgow coma scale (GLS) score, Canadian Neurological (CNS) Score, papillary asymmetry, pyramidal signs on non-hemiplegic side and locomotion, midline shift and ventricular extension of hematoma. At 1-months 10 patients died in each group. The primary and secondary end points were not significantly different between the two groups.

Conclusion : Low dose mannitol does not seem to be beneficial in patients with ICH.