International Journal of Advances in Medicine

Understanding the enigma of a novel pediatric disease, multisystem inflammatory syndrome in children: when COVID-19 throws a curveball at children's health

Maryam Maqsood — 2023-05-25

Multisystem inflammatory syndrome in children (MIS-C) is a rare and potentially life-threatening condition that has emerged as a post-infectious complication of COVID-19. MIS-C is characterized by widespread inflammation affecting multiple organ systems, including the heart, lungs, kidneys, and gastrointestinal tract. The condition primarily affects school-aged children and adolescents, with most cases occurring several weeks after a COVID-19 infection. The exact pathophysiology of MIS-C is not yet fully understood, but it is thought to result from an abnormal immune response triggered by the SARS-CoV-2 virus. The clinical presentation of MIS-C is highly variable, and patients may present with fever, rash, conjunctivitis, abdominal pain, vomiting, diarrhea, and cardiac dysfunction. Early recognition and diagnosis of MIS-C are crucial for the prompt initiation of treatment, which typically involves immunomodulatory therapy and supportive care. The diagnosis of MIS-C is based on a combination of clinical and laboratory findings, including elevated inflammatory markers, cardiac biomarkers, and evidence of recent SARS-CoV-2 infection. The management of MIS-C is challenging, and treatment strategies continue to evolve as our understanding of the condition improves. Ongoing research is focused on optimizing diagnostic and therapeutic approaches to improve outcomes for affected children. This review article provides an overview of the current state of knowledge regarding MIS-C, including its epidemiology, clinical presentation, diagnostic evaluation, and management strategies.

Pancytopenia as the initial presenting feature in multiple myeloma: a case series

Somnath S. Roy — 2023-05-25

Multiple myeloma is a plasma cell neoplasm characterized by abnormal proliferation of clonal cells in the bone marrow. Anaemia is generally the most common feature from hematologic aspect and bone pain being the other important symptom, but pancytopenia as the presenting feature is unusual. Here, we shared our experience of 3 cases with non-specific symptoms with pancytopenia which on through evaluation revealed our diagnosis. A hospital based observational descriptive case series was conducted wherein all the cases of multiple myeloma presenting with pancytopenia were included. Complete blood picture, peripheral smear, bone marrow aspirate and serum protein electrophoresis were reviewed and analysed. Pancytopenia as the initial presenting feature of multiple myeloma is an unique manifestation and diagnosing such cases require high degree of suspicion to avoid delay in the initiation of treatment.

Massive pleural effusion, what should we do in emergency department? a case report

Nicholas P. Limalvin — 2023-05-25

Indonesia has been known as an endemic country of tuberculosis (TB). Most of the cases are pulmonary TB, and pleural effusion is one of the common cases. Untreated pleural effusion can become massive pleural effusion, a true emergency case in the emergency room. In this report we present a 21-years-old female patient with new onset massive pleural effusion due to TB infection. A 21-year-old female patient with no previous medical illness came to ER with shortness of breaths since a week ago. Cough and unmeasured fever have been reported since a month ago. Tachypnea, extreme tachycardia, asymmetric chest movement, decreased vocal fremitus, dullness of percussion, and decreased left pulmonary sound were found. Chest x-ray showed a massive left pleural effusion with tracheal deviation. High flow nasal cannula was given due to blood gas analysis interpreting moderate respiratory distress. Thoracentesis was immediately performed with estimated 1200 CC yellow coloured fluid production. Other laboratory findings include hyponatremia and hypoalbuminemia. This patient was diagnosed with pleural effusion type pulmonary TB, treated with anti-TB drugs, mucolytic, corticosteroid, and analgesics. Serial chest x-rays showed improvement of pleural effusion. In developing countries like Indonesia, the most common causes of pleural effusion was TB infection besides malignancy. A massive pleural effusion diagnosis can be established with history taking, physical examination, chest sonography, chest x-ray, and/or CT-scan. Thoracentesis must be performed within minutes after massive pleural effusion was established.

A case report of metronidazole-induced encephalopathy in Bangladesh

Shahriar Mahmud — 2023-05-25

Metronidazole-induced encephalopathy (MIE) is a rare disorder that can be reversible but fatal if not recognized early. Here, the author presents a case of encephalopathy in a 36-year-old patient who took 500 mg of metronidazole three times daily for three weeks. The patient was classified as a probable MIE case on the Naranjo causality assessment scale. An interesting neuroimaging finding in this patient was an isolated dentate nucleus signal abnormality. Author aims to report reversible clinical and radiological features of MIE in this patient and compare them with documented cases in recent and old literature. Data from this case report may guide clinicians to make judicious considerations in the early detection of MIE and may influence future researchers to focus on identifying critical mechanisms of devastating adverse effects, predictability of neurotoxicity.

COVID-19 associated pulmonary aspergillosis-an unusual manifestation of COVID-19

B. Anusuya — 2023-05-25

A recently identified condition known as COVID-19-associated pulmonary aspergillosis (CAPA) is connected to the COVID-19 pandemic and is known as post-COVID complications. More data are awaited, and a consensus criterion was recently published in an effort to spur more research and registries to assist clinical decision-making. However, it is evident that CAPA imposes a COVID-19 illness course that worsens with increased morbidity and mortality. Here we present the case of a 53-year-old male patient admitted to our hospital after recovering from COVID-19. Due to his clinical condition, some investigation criteria were performed and Aspergillus fumigatus was identified in his culture test. Treatment was provided with posaconazole as a first-line drug, and the patient showed a good clinical outcome.

Henoch schonlein purpura in adults: a case report

Avtar Singh Dhanju — 2023-05-25

We describe a case of a young adult female with Henoch-Schonlein purpura (HSP) presenting with cutaneous and gastrointestinal manifestations. Biopsy revealed a leukocytoclastic vasculitis in the skin. Steroid therapy led to initial resolution of the symptoms followed by a relapse of rashes and subsequent introduction of azathioprine. HSP is the most common childhood vasculitis and uncommonly seen in adults. Early recognition of the disease, especially in the atypical age group, as in our patient, and appropriate intervention can mitigate the disease and limit organ damage.

Extra-hepatic portal vein obstruction leading to portal cavernoma cholangiopathy without liver dysfunction

Avtar Singh Dhanju — 2023-05-25

In adults, EHPVO mainly occurs following thrombosis, while in children it may be related to congenital malformations and/or neonatal umbilical venous catheterization. EHPVO leads to the cavernous transformation of the portal vein in the absence of recanalization. Portal cholangiopathy (also referred to as portal biliopathy) is common in patients with long-standing chronic PVT. It is due to compression of the large bile ducts by the venous collaterals (portal cavernoma) that form in patients with chronic PVT. Typically, symptoms of portal cholangiopathy include jaundice, biliary colic and pruritus.

A study of thyroid function profile in patients of chronic liver disease and its correlation with child Pugh score

Richa Giri — 2023-05-16

Background: Chronic liver disease (CLD) is a continuous process of inflammation, destruction, and regeneration of liver parenchyma, which leads to fibrosis and cirrhosis. Liver plays an essential physiological role in thyroid hormone activation and inactivation, transport, and metabolism, as well as the synthesis of thyroid binding globulin. A complex relationship exists between thyroid and liver in health and disease.

Methods: 103 patients of CLD were included in this study from December 2020 to September 2022. They were classified as per child Pugh scoring after clinical assessment and investigations. Serum TSH, FT3, FT4 levels were measured for all the patients.

Results: Out of 103 patients and it was found that 19 (18.44%) patients belonged CTP class A, 40 (38.83%) patients had CTP score of class B, while maximum 44 (42.71%) patients belonged CTP class C. There was significant positive correlation between CTP class and TSH values (p<0.001) with mean (SD) of CTP class A, B and C were 2.42 (0.76), 3.9 (1.02) and 5.91 (1.08) respectively. There was significant negative correlation between CTP class and FT3 values (p<0.001) and between CTP class and FT4 values (p<0.001).

Conclusions: Our study found that there was significant positive correlation of S.TSH values with severity of CLD as assessed by CTP score, while FT3 and FT4 were having significant negative correlation.

Effect of SGLT-2 inhibitor (remogliflozin) plus DPP4 inhibitor (vildagliptin) on diabetic nephropathy in patients with type 2 diabetes mellitus comparison with combination of metformin and sulphonylureas

Vishal Kumar Gupta — 2023-05-25

Background: Diabetes is leading cause of renal failure in entire world. Approximately 20-40 percent of patients with diabetes develop diabetic nephropathy. Newer drugs like SGLT-2 inhibitors and DPP-4 inhibitors are valuable option for Diabetic Nephropathy. Remogliflozin etabonate (RE) is the latest addition to the SGLT2 inhibitor class of drugs that have been recently approved in India for the management of T2DM.This study was conducted to elaborate effect of SGLT2 inhibitor (remogliflozin) plus DPP4 inhibitor (vildagliptin) on diabetic nephropathy in patients of Type 2 DM.

Methods: This hospital based, comparative, open label, randomized controlled trial has been carried out in our department during January 2020 to October 2022 on 60 patients. Group 1 was given metformin 500 mg BD and glimepiride 1 mg BD and group 2 was given FDC of remogliflozin 100 mg and vildagliptin 50 mg BD with 32 patients in group 1 and 28 patients in group 2. The study was approved by ethical committee of our institute.

Results: Mean (SD) of urine ACR in metformin and glimepiride group at screening, 12 weeks, 24 weeks, and at 36 weeks were 93.64 (53.92), 95.56 (52.76), 89.96 (50.22) and 90.9 (53.56) respectively mean (SD) of urine ACR in remogliflozin and vildagliptin group at screening, 12 weeks, 24 weeks, and at 36 weeks were 108.28 (68.5), 100.73 (55.5), 99.35 (55.71) and 75.1 (38.7) respectively. Mean (SD) of eGFR in metformin and glimepiride group at screening, 12 weeks, 24 weeks, and at 36 weeks were 59.62 (18.57), 61.2 (11.1), 60.06 (14.37) and 60.8 (13.3) respectively. Mean (SD) of eGFR in remogliflozin and vildagliptin group at screening, 12 weeks, 24 weeks, and at 36 weeks were 68.03 (16.35), 65.8 (7.96), 66.28 (15.13) and 68.4 (11.6) respectively.

Conclusions: Remogliflozin and vildagliptin combination has significant reduction of proteinuria and eGFR improvement when compared to metformin plus glimepiride.

Spectrum and risk factors for upper gastrointestinal bleed: an experience from multilevel teaching hospital of North India

Farhan Khan — 2023-05-25

Background: The aetiology of upper gastrointestinal bleed is variable in different geographical regions. Epidemiological data are helpful in knowing the burden of the problem. This study was conducted to know the etiological spectrum, mortality, morbidity, and predictors of outcome in patients with acute UGIB.

Methods: Cross-sectional observational study to be carried out in indoor patients presenting with upper GI bleed and to study the spectrum and risk factors associated with it at LLR and associated hospitals, GSVM Medical College, Kanpur during 2020-2022 and noted the clinical presentation, aetiology of bleed, and outcome.

Results: Out of 120 patients, 60(50%) had history of chronic alcohol intake, use of NSAIDS 12(10%), smoking 7 (5.83%), intake of spicy food 7 (5.83%), use of steroids 3 (2.5%), stressor present 3 (2.5%), not identified 10 (8.33%). Maximum no. of cases presenting with upper Gi bleed had oesophageal varices 55 (45.83%), esophagitis/gastritis/duodenitis 36 (30%), carcinoma upper GI 12 (10%) normal 11 (9.16%) GAVE 2 (1.66%) Mallory Weiss tear 4 (3.33%).

Conclusions: In our study it was found that the most common risk factor for upper GI bleed is chronic alcohol intake and the most common endoscopic finding in these patients were variceal bleed.

Clinical profile of patients presenting with mushroom toxicity in a tertiary care setup in Northeast India: with special focus on model for end-stage liver disease score as a predictor of disease outcome

Aritra Saha — 2023-05-25

Background: Ingestion of wild mushrooms leading to toxicity is a common phenomenon every year during the rainy season in Upper Assam, India. The model for end-stage liver disease (MELD) score was developed to predict mortality in a specific group of patients with decompensated chronic liver disease. It has also been used to predict mortality in patients with acute liver failure, which is also one of the dreaded complications of mushroom toxicity. There are only a couple of studies in the world that have studied MELD score as a predictor of outcomes in patients with mushroom toxicity and to the best of our knowledge, this is the first such study done in India.

Methods: In this hospital-based observational study, 35 patients aged >13 years with an alleged history of ingestion of wild mushrooms, but no other cause of hepatic dysfunction were included in this study. Disease outcome (discharged/expired) was correlated with both MELD score and day of presentation from symptom onset.

Results: The mean age was 32.54 years with a male-to-female sex ratio of 4:5 among the study participants. Gastrointestinal symptoms, including loose stool, vomiting, pain abdomen, and jaundice, were the most common. The MELD score was significantly higher in patients who succumbed to the toxin (p<0.05) and positively correlated with mortality (r=0.664, p<0.001) and a later day of presentation (r=0.226, p=0.123). A later-day presentation also positively correlated with mortality (r=0.227, p=0.189).

Conclusions: The MELD score can be used as a prognostic tool in patients with mushroom toxicity.

Unveiling the occurrence of diabetic ketoacidosis with SGLT2 Inhibitors: need for vigilance and careful monitoring

Anjali Srikanth Mannava — 2023-05-25

With great interest, we have read the case report titled “Euglycemic diabetic ketoacidosis (DKA)-a rare side effect of sodium-glucose co-transporter-2 inhibitor in a patient of type 2 diabetes mellitus with left ventricular dysfunction: a case report” published in the international journal of advances in medicine.