Anti-neutrophil cytoplasmic antibodies associated vasculitis with interstitial lung disease: a case report

Anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis is a necrotizing vasculitis that primarily affect small blood vessels of the airway and kidneys. The major clinicopathologic feature include microscopic polyangiitis and granulomatosis with polyangiitis. There are several studies done that have shown the association of interstitial lung disease (ILD) and ANCA vasculitis. Majority of the studies showed that the prognosis was bad in patients with AAV and ILD, then those without it, and patients with pulmonary fibrosis and ANCA had as low a prognosis as patients with IPF without ANCA. We hereby report a case of a female patient in her 70s who was been treated as a case of infection at different hospital, only to be diagnosed later as ANCA associated vasculitis with interstitial lung disease. Methylenetetrahydrofolate reductase (MTHFR) enzyme is one of the key enzymes involved in the metabolism of folate

COVID-19 associated meningoencephalitis or a neuropsychiatric manifestation of systemic lupus erythematosus-a diagnostic dilemma

The infection with SARS-CoV-2 is associated with fever and respiratory symptoms but is not limited to respiratory system only. Since its appearance, several neurological symptoms have been reported, most commonly headache and anosmia, as well as less frequent complications such as COVID-19-associated encephalitis and meningitis. In this case report, we report a 40-year-old female recently infected with SARS-CoV-2, who presented with history of high-grade fever, cough, breathlessness 12 days back followed by altered sensorium and restlessness. The patient was also found to have underlying systemic lupus erythematosus which surfaced post-COVID-19 infection. Cerebrospinal fluid (CSF) analysis was done and the patient received IVIG therapy and showed dramatic improvement. SARS-CoV-2 has been implicated in development of autoimmune diseases

The copper conundrum: a case of toxicity and altered mental status in a young male with opioid dependency

Copper is a trace element with higher concentrations in the brain, liver, and kidneys. Its toxicity is rare in humans because of its homeostatic mechanisms. This case highlights a 30-year-old male with a history of opioid abuse and occupational exposure to metallurgy. Despite treatment, a gradual neurological worsening prompted us for heavy metal screening and nerve conduction velocity study (NCV) which revealed copper toxicity and demyelinating polyneuropathy. Following the initiation of D-penicillamine therapy, he showed gradual improvement. The coexistence of opioid abuse and dependency posed challenges in the clinical presentation, necessitating a comprehensive approach to effectively manage both opioid withdrawal and evaluation for other toxic substances

Primary adrenal insufficiency presenting with neuropsychiatric illness

Adrenal insufficiency is characterized by decreased production of glucocorticoids from adrenal cortex, either due to a primary adrenal or a secondary pituitary etiology. Neuropsychiatric symptoms and signs could be the first presenting symptoms or the only presentation of adrenal insufficiency and are relatively less explored in patients with adrenal insufficiency and less understood. Patients with chronic psychiatric symptoms, namely depression and anxiety should be evaluated for association with adrenal insufficiency

Post COVID nocardiosis-an opportunistic enemy

Nocardia is an opportunistic infection seen mostly in immunocompromised individuals. It has become an important pathogen especially in these post covid times in which multiple individuals had to go through high dose corticosteroid therapy as part of their severe COVID-19 treatment. We present a 62 years old male with diabetes mellitus and hypertension who had previously been hospitalized for a month for COVID-19 and received high dose corticosteroids for the same. He presented again one month later with symptoms of fever and breathlessness and was worked up extensively for infections in which all his investigations came negative. For suspicion of opportunistic pathogen his HRCT thorax was done which showed consolidation and cavitation in lung along with other infective changes. In view of HRCT thorax findings bronchoscopy was done and bronchoalveolar lavage was sent for examination which grew Nocardia beijingensis on culture. Cotrimoxazole was started for the patient and 3 days after the initiation of therapy he became afebrile and was weaned off of oxygen support gradually over next one month

A rare case of isoniazid induced sideroblastic anemia

Sideroblastic anemia is a rare cause of anemia. Most of it accounts for the genetic cause, while drug induced is still uncommon. Our patient, a 20 year old female, is a known case of right frontal tuberculoma on ATT presented with complaints of generalized weakness and loss of appetite. On evaluation, she was found to have severe anemia and bone marrow studies confirmed it to be sideroblastic anemia. On revisiting the history, it was noted that she was not taking pyridoxine supplements as advised along with antitubercular drugs. Our patient is one among the few documented cases of Isoniazid induced sideroblastic anemia.This case needs attention because it is a preventable cause of anemia and the clinicians need to be aware about the compliance of the patient with the supplementary drugs.

Visceral leishmaniasis escaping the diagnosis and withstanding treatment in a case of recurrent pyrexia

Though visceral leishmaniasis (VL) is the leading parasitic infection causing deatharound the world after malaria, it is a less suspected cause of pyrexia of unknown origin (PUO). We present a case of a middle aged man who was diagnosed with VL only months later owing to the stealthily masquerading disease as also to a generally low index of suspicion for it. A 59-year-old from Uttarakhand presented to us with complaint of fever of a few weeks duration. He was found to have a bicytopenia with elevated liver enzymes. Routine imaging studies were non-contributory. Cultures revealed candidemia while tests for viral and other atypical infections were negative. A bone marrow examination (BME) revealed haemophagocytosis. Positron emission tomography–computed tomography (PET-CT) showed mildly FDG avid hepatosplenomegaly. He was treated as a case of candidiasis with secondary hemophagocytic lymphohistiocytosis (HLH) and was discharged. He was readmitted months later with recurring fever. Repeat investigations revealed pancytopenia with marked hepatosplenomegaly. A repeat BME, however, revealed Leishmania donovani (LD) bodies. Patient was treated with liposomal amphotericin B (LAmB) and discharged. Though the patient’s symptoms improved soon after, he was again admitted a couple of months later and found to have VL persisting in the BM aspirate. This report underscores the need to extensively evaluate cases of PUO rather than summarily dismissing them as routine. VL is one of the less suspected etiologies despite being the second largest parasitic killer

Iron pill associated duodenitis: a less recognised clinical entity

Iron supplementation is a widely prescribed treatment for anemia, but its association with gastrointestinal complications, specifically duodenitis, remains inadequately acknowledged in clinical practice. One of the common oral iron preparations to treat iron deficiency anemia is ferrous sulphate. Iron preparations have been known to cause gastric side effects, including gastritis and duodenitis. This case report explores the emerging concern of iron pill-associated duodenitis, shedding light on the potential adverse effects of oral iron supplementation on the duodenal mucosa. Existing literature and clinical cases are reviewed to highlight the connection between iron pill consumption and duodenal inflammation. From asymptomatic cases to severe symptoms like abdominal pain and gastrointestinal bleeding, the clinical spectrum is diverse. Histopathological analysis of endoscopic biopsies reveals characteristic features of duodenitis linked with iron deposits, raising concerns about long-term consequences. In conclusion, this case underscores the significance of recognizing iron pill-associated duodenitis as a distinct clinical entity, necessitating further investigation for optimized patient care and the safe administration of iron supplements in managing anemia.

Study of hematological profile of systemic lupus erythematosus

Background: Hematological abnormalities are prevalent in systemic lupus erythematosus (SLE), with approximately 72% of patients experiencing anemia, primarily in the form of autoimmune hemolytic anemia. Other manifestations include leukopenia (32%), lymphopenia (54%), and thrombocytopenia (23%). This study aimed to further investigate these hematological manifestations, which may serve as presentations of SLE and might be overlooked if suspicion levels are low. Methods: A descriptive observational study was conducted over 18 months at a Sir Ganga Ram hospital, a tertiary care centre. One hundred thirteen SLE cases, comprising newly diagnosed patients and previously diagnosed patients’ records, were reviewed, with 13 cases excluded based on exclusion criteria. One hundred patients with hematological abnormalities and fulfilling ≥4 SLICC criteria for SLE diagnosis were included in the study. Results: One hundred cases of SLE with hematological abnormalities (88 women, 12 men) were analyzed. At presentation, 83% (n=84) of patients displayed hematological manifestations. The most prevalent abnormality was anemia, present in 72% of the study group, with a mean hemoglobin level of 10.073 gm/dl. Additionally, leukopenia, lymphopenia, thrombocytopenia, and pancytopenia were observed in 32%, 54%, 23%, and 14% of cases, respectively. Neutropenia was detected in only 5% of cases. Conclusions: Hematological manifestations are the most common presenting signs of SLE in North India. Anemia, with a multifactorial basis, is the most frequent hematological abnormality throughout the disease course. A high index of suspicion is crucial when evaluating cases of anemia in daily clinical practice

Hepatic brucelloma

The liver is commonly affected in human brucellosis, reflected the effect of Brucella on the RES (reticuloendothelial system) (Akritidis et al. 2007 [1], Sadia Pérez et al. 2001 [2]). The formation of liver abscess (brucelloma) is uncommon (Rovery et al. 2003 [3]). Here we report an interesting case of brucellosis with a liver abscess in a young immmunocompetent individual with no known comorbidities