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   Table of Contents - Current issue
October-December 2020
Volume 8 | Issue 4
Page Nos. 163-219

Online since Friday, October 23, 2020

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Editorial p. 163
Manjunath Premanath
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Biomarkers in heart failure: Work still half done? p. 164
Nagaraj Desai, CR Venkatesh
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Subclinical hyperthyroidism p. 167
Mala Dharmalingam, Rakesh Bobba
Subclinical hyperthyroidism (SH) is a relatively common disorder; it is defined as a condition in which the thyroid hormones thyroxine (T4) and triiodothyronine levels (T3) are normal with low or even undetectable thyroid-stimulating hormone (TSH) levels. SH may be caused by exogenous or endogenous factors with TSH suppressive therapy in differentiated thyroid cancer or unintentional over-replacement L-T4 therapy being the most common causes. Frank symptoms of hyperthyroidism is most often absent. Patients often present with goitre or for other symptoms of mild thyroid hormone excess such as headache, reduced feeling of well-being, and inability to concentrate. SH leads to increased risk of cardiovascular morbidity and mortality, it may accelerate the development of osteoporosis, and increase bone vulnerability to trauma, especially in postmenopausal women and elderly. It reduces the quality of life, affecting both the psycho and somatic components of wellbeing. Diagnosis of SH is confirmed by repeated testing of TSH spaced months apart in the presence of normal free T3 and T4 concentrations. Radionuclide uptake scan aids us in the diagnosis of the cause of SH. The treatment of SH is similar to the treatment of overt hyperthyroidism, it should be based on the underlying etiology.
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Coronavirus disease 2019 and the kidney Highly accessed article p. 172
Ravi Jangamani, Chakravarthy Thirumal, Sankaran Sundar
Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by severe acute respiratory syndrome coronavirus-2, primarily manifesting as acute respiratory illness but can affect multiple organs. The COVID-19 individuals have varied renal manifestations which includes acute kidney injury, proteinuria, and hematuria. The involvement of kidneys indicates the severity of illness and is one of the determinants of mortality. The individuals with chronic kidney diseases (CKD), on dialysis and with kidney transplantation are at higher risk of severe COVID-19 infection due to the poor immune response and a high prevalence of comorbidities. Here, we review the effects of COVID-19 on kidneys and its management in CKD, dialysis, and kidney transplantation individuals.
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To study gamma-glutamyl transferase levels in heart failure p. 179
Fida Hussain Mitha Bhai, Sangram Biradar
Background and Aims: Serum gamma-glutamyl transferase (Sr.GGT) is associated with incident cardiovascular diseases and is a potential risk factor for disease mortality. We investigated the relevance of circulating Sr.GGT levels in heart failure (HF) patients. Materials and Methods: About 50 patients admitted with diagnosed HF according to Framingham's clinical criteria, irrespective of etiology, and type of HF were enrolled in the study and their baseline Sr.GGT levels were estimated. They were grouped into ischemic and nonischemic (valvular) cause of HF. Type of HF was based on the ejection fraction (EF%) on echocardiography reduced the EF (<40%), mid-range or preserved EF >40%). Statistical analysis was presented as frequency (percentage) and continuous as mean ± standard deviation. Inferential statistics such as Chi-square test/Fischer's exact test was used. Results: The mean age of the study patients was 58.20 ± 14.98 years. Both genders were homogeneously spread across the different age groups in the study. It was found that Sr.GGT levels were best correlated in the age groups below 65 years. Significant association was seen when patients were studied by stratifying them gender wise, divided into quartiles. Valvular heart disease and its association with Sr.GGT levels were found to be statistically significant (P = 0.001). Whereas no association was found in the given sample between coronary artery disease/ischemic heart disease and Sr.GGT levels. Significant association in patients with comorbid conditions was found, indicative that comorbidities contributed as a confounding factor in the study.Conclusion: This study is limited by its observational nature; it does not permit conclusions on causal relationships. Sr.GGT levels done at baseline in patients with HF may not be helpful to prognosticate HF. Serial follow-up studies in a larger sample size are required.
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A study of the comparative clinical profiles of scrub typhus, spotted fever group, and typhus group rickettsial infections at a rural tertiary care hospital p. 184
Vasantha Kamath, B Hima Bindu, Shreyashi Ganguly
Background: The rickettsioses represent a major cause of acute febrile illnesses worldwide. The greatest challenge lies in diagnosing rickettsioses in a timely manner early in the course, when antibiotic use is most effective. In most cases clinical suspicion together with a positive serology is employed to make the diagnosis of rickettsiosis. Aim and Objective: To study the syndromic differences, if any, amongst the three groups of rickettsial infections present in India. Methods: This was a cross-sectional observational study that evaluated a total of 172 cases of rickettsial fever out of a pool of 778 cases of acute febrile illness between the June 2017 and March 2019. A careful search for eschar, lymphadenopathy and rashes was made. Weil Felix test was done after exclusion of other infections like malaria, dengue, enteric fever. To avoid the possibility of false positives, a single titer dilution >1:320 was considered positive for rickettsioses. Results: Fever was seen in all cases. Myalgia (81·5%), headache (72·8%), and splenomegaly (51·9%) were common in scrub typhus. Eschar was seen in only 8·4% cases. Spotted fever group presented with fever of shorter duration of less than seven days (64·7%), and gastrointestinal symptoms like vomiting (74·5%) and diarrhea (13·7%) were predominantly seen. Spotted fever group had macular rash as predominant sign. Typhus group presented with fever of longer duration of more than fourteen days (50%) and respiratory symptoms like cough (65%). Hepatomegaly was present in 35% and lymphadenopathy in 7·5%. Conclusion: Rrickettsial infections remain a diagnostic challenge in resource-poor settings. Therefore, it is important to recognize the clinical features promptly, include rickettsioses in the differential diagnoses, and consider early initiation of appropriate treatment.
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Comparison of the nonfasting and fasting lipid profiles of the patients admitted in the cardiology department of a tertiary hospital in Bangladesh p. 190
Kantish Kumar Sarker, A B. M. Kamrul-Hasan, Md Abdul Bari, Mirza Md Nazrul Islam, Shamim Chowdhury, Lita Rani Pramanik
Background: Evidence relaxes the obligation of fasting for a lipid profile test. There is a scarcity of data comparing the fasting and nonfasting lipid profiles in our setting. Objectives: We conducted this study to observe the differences in the components of the lipid profile between the nonfasting and fasting states. Materials and Methods: In this cross-sectional study, 275 patients admitted in the cardiology department of a tertiary hospital in Bangladesh were evaluated; the study participants were categorized as having an acute myocardial infarction (AMI), unstable angina (UA), and no acute coronary syndrome (non-ACS). Serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) were measured in both nonfasting and fasting states in all. Results: All the measured components of the lipid profile, e.g., serum TC, HDL-C, LDL-C, and TG, were higher in the nonfasting state than the fasting state in the study participants with AMI. However, those with UA and those without ACS (non-ACS) had no significant differences in fasting and nonfasting levels of TC, HDL-C, and LDL-C through their TG level was significantly higher in the nonfasting state. Conclusion: Nonfasting blood sample, which is more convenient, may be used for assessing the lipid profile in the majority of the patients advised for the test.
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A case series of atypical manifestations of dengue p. 194
C H. Monica Lakshmi Priyanka, B Hima Bindu, B Nivea, MJ Jacob
Dengue fever is an arthropod-borne viral illness caused by Flavivirus and transmitted by Aedes aegypti mosquito. With rising burden of disease, atypical manifestations have increased. In our case series, we report five cases of serologically proven dengue-positive patients (by immunochromatographic dengue card test) with atypical manifestations. The first two patients presented with dengue encephalitis and the next two patients presented with viral pneumonia. The second, fourth, and fifth cases were dengue in cirrhotic patients leading to decompensated liver disease. The fourth case succumbed to death due to refractory shock. We should have a high index of suspicion and knowledge to detect atypical manifestations of dengue fever as they are more fatal and are increasing in incidence. In preexisting liver disease, chances of bleeding are high even though platelet counts are not very low. Only appropriate timely intervention can prevent morbidity and mortality.
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A rare case of progressive multifocal leukoencephalopathy – As a presenting manifestation of AIDS p. 199
S Sumangala, Mohd Zeeshan Ali, Mushtaq Saudagar
Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating central nervous system (CNS) infection disease that exclusively affects immunocompromised individuals. John Cunningham virus, the etiologic agent for PML, is ubiquitous in the general population but rarely causes disease in immunocompetent hosts. Here, we present a 35-year-old male with left hemiparesis and loss of vision, diagnosed as PML as the first AIDS-defining event, with previously undiagnosed human immunodeficiency virus (HIV) infection. PML is an underinvestigated CNS infection seen in HIV patients usually with advanced disease. We present an unusual case report, where PML occurred as the first AIDS-defining event in a patient with previously undiagnosed HIV infection. This case is presented to enlighten the physicians regarding the clinical entity of PML to be suspected in HIV-infected patients who present with focal neurologic deficits even in undiagnosed infection.
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When you never thought it would be me p. 203
KR Raveendra, H Sivaranjani, Shivakumar Hrishikesh
Tuberculosis, both pulmonary and extrapulmonary, is a procoagulant state, which can lead to deep-vein thrombosis and thromboembolism. Rifampicin, the antitubercular drug by itself, can cause a procoagulant state. Here, we describe the case of a patient diagnosed with pulmonary tuberculosis, on antitubercular treatment for 25 days, who developed pulmonary thromboembolism.
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A petit telomere – A catalyst for bone marrow failure p. 206
AC Nirmala, G Madhu
Dyskeratosis congenita (DC) is a rare inherited disorder estimated to affect 1 in 1 million people characterized by rapidly depleting telomere length causing premature apoptosis or senescence results in progressive bone marrow failure. It is also known as Zinsser–Engman–Cole syndrome, and it was first described in 1906. The classic triads of DC include reticulated skin hyperpigmentation, nail dystrophy, and oral leukoplakia. Here, we report a case of a 20-year-old female presented with anemia symptoms and, on evaluation, diagnosed as bone marrow failure secondary to DC.
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Hyperhomocysteinemia – A treatable cause of cerebral venous thrombosis in young p. 209
Vivekanand Kamat, Suresh Harsoor
Mild hyperhomocysteinemia is an established risk factor for deep vein thrombosis. Here, we report a case of a 28-year-old male with complaints of severe headache and vomiting for 7 days, and he also had two episodes of generalised tonic clonic seizures (GTCS) type of convulsions. Magnetic resonance imaging + magnetic resonance venography showed acute infarct with hemorrhagic transformation in the right occipital region and venous thrombosis of the right transverse sinus, right sigmoid sinus, and superior sagittal sinus. All laboratory investigations including protein C, S, and B12levels were found to be normal except for serum homocysteine which was 29.20 μmol/L. After anticoagulation therapy, this young patient completely recovered without any residual neurological deficit. Hence, we suggest that hyperhomocysteinemia should also be a risk factor for cerebral venous thrombosis (CVT). Since this condition can be effectively and safely corrected by drugs, we suggest that homocysteine levels should be routinely determined in patients with idiopathic CVT, and even mildly increased levels corrected pharmacologically, in the hope of reducing the risks associated with this condition.
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ECG diagnosis p. 212
Neha Sukhani, Suresh V Sagarad
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Is the society in india envious of its doctors? A doctor's perspective p. 214
B Sadananda Naik
It is very disheartening that society in India which has a long history and tradition of revering its medical professionals is slowly and steadily becoming indifferent to them. This is a write up on this issue from a doctor's perspective.
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Obituary p. 216
Vasantha Kamath
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A case report of pulmonary mucormycosis p. 218
Mahmood Dhahir Al-Mendalawi
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Retraction: Patient based factors influencing drug compliance in a tertiary care hospital in Mysore.. A pilot study p. 219

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