Case Reports

Abstracts of the 29th Annual Scientific Meeting of the Indonesian Heart Association (ASMIHA) 1st ASMIHA Digital Conference, 23-25 October 202

Cardiac Epithelioid PEComa: Report of Two Cases and Review of the Literature

Cardiac PEComa is very rare. We reported two cases of epithelioid PEComas, one in an adult and one in a 2-year-old child. Both tumors were composed of sheets of epithelioid cells with coagulation necrosis. In addition, the adult case showed marked nuclear atypia and high mitotic activity with atypical mitosis and the pediatric case showed unusual clear cell features. Immunohistochemically, both tumors were positive for HMB-45 and SMA and negative for S100 and cytokeratin. Electron microscopy was performed in the pediatric case and showed premelanosomes. The adult patient developed extensive metastasis indicating malignant behavior. Prior to the two cases, only 5 other cases of cardiac PEComa were reported and the literatures are reviewed

Validity of Siriraj Stroke Score in Differentiating Cerebral Infarct and Haemorrhage in South Indians

INTRODUCTION: Computed tomography (CT) scan is an accurate, safe, non-invasive procedure routinely used as an investigative tool for stroke to distinguish between infarction and haemorrhage. Computed tomography scanning of brain is expensive in both the initial investment and maintenance. In developing countries like India, cost and availability constraints prohibit its widespread use especially in rural areas. Clinical stroke scores were developed to overcome these limitations. Differential diagnosis between infarction and haemorrhage can be made on clinical grounds with aid of Siriraj Scoring System. CT scan is not readily available in semi-urban and rural areas and the scoring systems will then come into play in differentiating the stroke subtype. This study is being done to determine the sensitivity, specificity of Siriraj score AIMS AND OBJECTIVES 1. To differentiate between cerebral infarct and intra cerebral hemorrhage on the basis of Siriraj Stroke Score. 2. To find out the sensitivity, specificity and overall accuracy of the scoring system by comparing it with the CT scan findings. MATERIALS & METHOD: Cross-sectional study was conducted among patient from general medicine ward of Govt. Rajaji hospital Madurai during the period of March 2016 to august 2016. Study included 60 cases of stroke. Subjects believed to fulfill all eligibility criteria, and none of the exclusion criteria were included in the study. METHODOLOGY: On admission detailed history and thorough clinical examination including neurological assessment will be carried out. Patients will be assumed to be fully conscious if they had a score of >13 on the Glasgow Coma Scale (GCS), drowsy if they had a GCS score of 8–13 and unconscious if they scored <7. Siriraj Stroke Score will be calculated and compared with the CT findings done on admission. A radiologist from the hospital, blind to the clinical features, will classify the CT brain scans as either infarction or haemorrhage. Siriraj Stroke Score (SSS) will be calculated using the formula = (2.5×level of consciousness) + (2×vomiting) + (2×headache) + (0.1×diastolic blood pressure) - (3×atheroma markers) -12. RESULT: Our study included 60 patients. The mean age of the patients was 60.2 years. 65 % were males and 35% were females.75 % patient had infarction in the CT scan. 25% patients had haemorrhage on CT scan.51.66% were predicted on siriraj score to have ischemic stroke out of 45 infarction cases. 30% were predicted to have haemorrhagic stroke on siriraj score. 18.3% were inconclusive. In this study, Siriraj score showed positive predictive value of 80.64% for ischemic stroke and negative predictive value of 78.57% for hemorrhagic stroke and the P value is 0.015 (significant). CONCLUSION: Based on clinical variables such as level of consciousness, blood pressure, atheroma markers and the presence of headache and vomiting, Siriraj Stroke Score, a clinical scoring can be used for the bedside diagnosis of the nature of the lesion in stroke patients where CT scan is not available immediately

Characterization of alar ligament on 3.0T MRI: a cross-sectional study in IIUM Medical Centre, Kuantan

INTRODUCTION: The main purpose of the study is to compare the normal anatomy of alar ligament on MRI between male and female. The specific objectives are to assess the prevalence of alar ligament visualized on MRI, to describe its characteristics in term of its course, shape and signal homogeneity and to find differences in alar ligament signal intensity between male and female. This study also aims to determine the association between the heights of respondents with alar ligament signal intensity and dimensions. MATERIALS & METHODS: 50 healthy volunteers were studied on 3.0T MR scanner Siemens Magnetom Spectra using 2-mm proton density, T2 and fat-suppression sequences. Alar ligament is depicted in 3 planes and the visualization and variability of the ligament courses, shapes and signal intensity characteristics were determined. The alar ligament dimensions were also measured. RESULTS: Alar ligament was best depicted in coronal plane, followed by sagittal and axial planes. The orientations were laterally ascending in most of the subjects (60%), predominantly oval in shaped (54%) and 67% showed inhomogenous signal. No significant difference of alar ligament signal intensity between male and female respondents. No significant association was found between the heights of the respondents with alar ligament signal intensity and dimensions. CONCLUSION: Employing a 3.0T MR scanner, the alar ligament is best portrayed on coronal plane, followed by sagittal and axial planes. However, tremendous variability of alar ligament as depicted in our data shows that caution needs to be exercised when evaluating alar ligament, especially during circumstances of injury

Case series of breast fillers and how things may go wrong: radiology point of view

INTRODUCTION: Breast augmentation is a procedure opted by women to overcome sagging breast due to breastfeeding or aging as well as small breast size. Recent years have shown the emergence of a variety of injectable materials on market as breast fillers. These injectable breast fillers have swiftly gained popularity among women, considering the minimal invasiveness of the procedure, nullifying the need for terrifying surgery. Little do they know that the procedure may pose detrimental complications, while visualization of breast parenchyma infiltrated by these fillers is also deemed substandard; posing diagnostic challenges. We present a case series of three patients with prior history of hyaluronic acid and collagen breast injections. REPORT: The first patient is a 37-year-old lady who presented to casualty with worsening shortness of breath, non-productive cough, central chest pain; associated with fever and chills for 2-weeks duration. The second patient is a 34-year-old lady who complained of cough, fever and haemoptysis; associated with shortness of breath for 1-week duration. CT in these cases revealed non thrombotic wedge-shaped peripheral air-space densities. The third patient is a 37‐year‐old female with right breast pain, swelling and redness for 2- weeks duration. Previous collagen breast injection performed 1 year ago had impeded sonographic visualization of the breast parenchyma. MRI breasts showed multiple non- enhancing round and oval shaped lesions exhibiting fat intensity. CONCLUSION: Radiologists should be familiar with the potential risks and hazards as well as limitations of imaging posed by breast fillers such that MRI is required as problem-solving tool

A Study on Patchavatham (பட்ச வாதம்)

AIM AND OBJECTIVES: “Nature is Man ad Man is Nature” A close relationship is found to exist between the external world and the internal system of man. Man is greatly affected by the external environment, diet, unhealthy lifestyles, physical & psychological stresses which in turn affects the internal systems of body. Annually millions of people worldwide suffer from stroke [PATCHA VATHAM] today and out of that 5.5 million die and another 5 million left permanently disabled. The incidence of Patcha vatham has increased in fold due to diseases like diabetes mellitus, hypertension, syphilis, tumor, trauma, epilepsy, infections, and also by unhealthy life styles, diet etc. Today Patcha vatham is the leading cause of adult disability and physical deformity. But the interesting fact about Patcha vatham is that it can be manager easily if diagnosed in early hours and medical attention is sought, the damage can be minimized and recovery can occur. Siddha medicine is very much effective in treating the physical disability in Patcha vatham. So the author has conducted a clinical study on Patcha vatham for the welfare of human race. The Internal drug “valladhagi chenduram” in which main constituents are ‘serankottai’[semecarpus anacardium], and ‘Lingam’ [cinnabar], are very potent and proven drugs for the treating the diseases of loco motor system. Also the constituents of the external drug “Mashathy thylam” ‘ulunthu’ [VIGNA MUNGO], ‘aamanakku ver’ [RICINUS COMMUNIS], ‘sitramutti’ [Pavonia], and sesame oil have potent Antivadha property. The external medicine is given in the form of thylam. The clinical features of Patcha vatham was comparable to stroke or hemiplegia in modern medicine. The clinical study was conducted in 20 inpatients and 20 out patients in post graduate sirappu maruthuvam wards in Govt Siddha medical college palayamkottai. The patients were advised to come for regular follow up to study the disease. The main aim of the study on Patcha vatham was i. To collect the evidences from the ancient literatures. ii. To control the predisposing factors. iii. To study the efficacy of trial drugs. iv. To correlate the incidence of Patcha vatham with reference to sex, age, socio economic status, family history, habits, trauma, thinaigal and paruva kaalangal. v. To study how the disease alters the normal systems of the body in respect to mukkutrangal, udal kattugal, kanma inthiriyangal and manomaya kosam etc and how it is diagnosed by envagai thervugal, neerkuri and neikuri etc. vi. To know the extent of correlation of etiology, classification, symptomology, diagnostic methods and treatment in line with allopathic system of medicine. vii. To conduct clinical trial on patients with Valladhagi chenduram and Mashathy thylam in treating Patcha vatham. viii. To emphasize the role of ‘Thokkanam’ using medicated oils in rehabilitating the patient. ix. To study the relationship of food habits in altering the disease process and the role of ‘pathiyam’ x. To use the available modern parameters in investigation side to confirm and to know the prognosis. xi. To conduct the biochemical analysis and study about the chemical contents of the drugs. xii. To study about the pharmacological action of the trial drug in experimental animals. xiii. And also to know the clinical toxicity or adverse effects of the trial drug if any. SUMMARY: The research work on “PATCHA VATHAM” was chosen with an intention to give solace to the patients who are suffering from the disease. The author had a chance of referring many siddha literatures and collected more information. Medicines meant for research study where towards the patient is collected from both siddha system as well as modern system to medicine and a case sheet was prepared. (Model case sheet is affixed at the end of this dissertation book) Separate case sheets were maintained for every patient who were admitted in the In-patient ward. Twenty patients were treated in the In-patient and another twenty patients in the out patient ward. The internal medicine Valladhagi chenduram 1g thrice a day with hot water after food and the external medicine Mashathy thylam for the external application with Thokkanam at the sides where affected to the patients. The patients who were also treating with Yogaasanam Piranaayaamam, Thiyanam, Thokkanam, Varmam as supportive therapies along with main theraphy have got good and quick relief than the other patients. The favourable effects of the drugs of the treatment good relief was reported within 10 days in mild cases, within 20 days in moderate cases and within 25 days in severe cases. The follow up study was done in the out-patient department. Exercises to affected limbs and face were also advised to all patients. At the time of discharge relief or improvement was observed clinically and there was maintenance of physiological conditions seen in all patients. The twenty patients who were treated in out-patient ward also good relief. Medicines were given to the patients until most of the symptoms were relieved as per siddha medicine it was regarded as a cure from the disease. No toxic or side effects were observed clinically or reportedly in any patients during the course of treatment and the follow up study. From the clinical study it could be inferred that treatment with trial drugs considerably improves the functions of, 1. Viyaana, which is responsible for all the movement in the body and also sensory and motor activities. 2. Abaanan, which is responsible for defaecation micturition, menstruation, parturirtion and ejaculation. 3. Naagan, which is responsible for movement of the eye ball, laziness, lassitude, quarrelling and arguing 4. Dhevathaththan which is responsible for movements of the eye ball, laziness, lassitude, quarreling, arguing begging and much anger. 5. And samaanan which is responsible for normal digestion and correction of other vaayus. It could be also inferred that the trial drugs inhibit further vascular disorders and regulate the other physiological and biological processes of the body. Research findings reveal bout the disease and its impact in the body. Statistics taken the help of details in the case sheet were give clear knowledge about the disease. Available investigations in modern medicine were also considered for diagnosis and to follow the prognosis of the patients. The efficacy of the trial drugs were studied by bio-chemical analysis and pharmacological evaluations. CONCLUSION: When the internal medicine Valladhagi chenduram administered to the pakka vaadham patient along with Mashathy thylam for external application have a good relief. Good clinical improved was observed in 13 (65%) patient out of 20 inpatient and 14 (70%) out patient. Moderate clinical improvement was observed in 2 patients out of 20 inpatients and 4 out-patients. Partially clinical improvement was observed in 5 patients out 20 in-patient and 2 out-patient ward. Patient who had followed Yoga, Pranayamam, Thiyanam, Thokkanam, and Dietary advice have got good relief than others. Because of engorging result clinically study may undertake with large number of patient with same drug with create a new era in the field of siddha medicine especially in the treatment of this diseases Patchavatham. It may through light on relieving the patient from the clutches of crippling by this disease