Changing patterns and outcome of Dengue infection; report from a tertiary care hospital in Pakistan

Objective: To identify predictors of outcome in patients with Dengue Infections at a tertiary care hospital and to analyze that if pattern of Dengue infection is changing in the past two years. Methods: We reviewed 225 cases of confirmed dengue virus infection. The diagnosis was confirmed by presence of IgM antibodies against Dengue by ELISA in addition to fever according to WHO criteria. Results: From years 2000-2004, 30(73%) had Dengue Fever (DF), 10(24%) had Dengue Haemorrhagic Fever (DHF) and 1(2.4%) had Dengue shock syndrome (DSS) while after 2005, 107(58%) had DF, 71(39%) had DHF and 6(3%) had DSS. Six patients (2.6%) died. Presence of shock (OR 2.9, 95% CI; 1.7-6.2), coma at presentation (OR 1.89, 95% CI; 1.02-3.3) and seizures (OR 1.6, 95% CI; 0.9-3.0) were important predictors of mortality. Conclusion: These findings are suggestive of a change in pattern and outcome of Dengue at our institution. Larger data set from all around the country is needed to comment on epidemicity and endemicity pattern of the dengue in Pakistan (JPMA 58:488;2008)

Pontine haemorrhage due to chondrosarcoma of the skull base

A young adult presented with acute weakness of right side of body and slurring of speech. An initial brain CT scan showed a pontine haemorrhage, however MRI done a few days later revealed a mass in the left parapharyngeal space. Histopathology of the mass revealed that it was a chondrosarcoma. Subsequently the patient was initially treated with chemotherapy and radiotherapy and later surgery. Skull base chondrosarcomabe is to be included in the differentials of a young patient presenting with signs consistent with pontine haemorrhage

Not All Orbitopathy Is Graves’: Discussion of Cases and Review of Literature

IntroductionGraves’ orbitopathy is the extra thyroidal manifestation of Graves’ disease and the most common cause of exophthalmos. It is also known as thyroid-associated orbitopathy (TAO) as it occasionally occurs in euthyroid or hypothyroid patients with chronic thyroiditis. 5% of patients with Graves’ orbitopathy can be euthyroid or hypothyroid as they have low titers of anti-thyrotropin-receptor antibodies, which are difficult to detect in some assays. Orbitopathy has also been seen in a small percentage of patients with Hashimotos thyroiditis. The eye involvement in Graves’ is frequently bilateral and symmetric. These patients pose few diagnostic difficulties when the ocular findings occur concomitantly with the thyroid disease. However, when unilateral and asymmetric ocular findings occur with normal or mildly abnormal thyroid function tests, alternate etiologies should also be pursued. We aim to discuss some conditions like sarcoidosis, lymphoma, orbital pseudotumor, and orbital malignancy that mimic TAO.CasesThree patients were referred to us with concern for Graves’ orbitopathy. After further work-up, we diagnosed the first patient with specific orbital myositis from sarcoidosis. Our second patient had CD10-positive B-cell lymphoma. Our third patient had orbitopathy likely secondary to Hashimotos or orbital pseudotumor.ConclusionOur cases and discussion describe some other conditions that clinically mimic TAO and the importance of pursuing further work-up for accurate diagnosis when presentation of orbitopathy is atypical

Encephalitis and myelitis associated with dengue viral infection Clinical and neuroimaging features

Objectives: The objective of this study was to identify clinical and neuroima-ing features and outcome of Patients with encephalitis and myelitis associated with dengue viral infection. Patients and methods: We retrospectively reviewed 225 cases of dengue viral infection. The diagnosis of dengue was confirmed by serology (presence of IgM antibodies). Results: Six Patients (3%) had evidence of neurological infection (encephalitis: 5 Patients, encephalomyelitis: I Patient). Age range was 18-35 years (Mean 27 years). Five Patients (83%) were women. All Patients (100%) had drowsiness, five Patients (83%) had fever, four Patients (67%) presented with seizures and one Patient presented with paraparesis (16%). All patients had elevated CSF cell count (range 25-102, mean 61) with predominant lymphocytes. Five Patients (83%) had abnormal CT or MRI scan. Cerebral edema was present in three Patients. Other findings included low density signals in right temporal and occipital lobe (1 Patient), bi temporal hyperintensi ties and meningeal enhancement (1 Patient), Frontal and subcortical hyperintense lesion (1 Patient) and hyperintense lesion on T2 in Pons and cervical and thoracic spinal cord (1 Patient). EEG was done in four Patients and showed generalized slowing (2 Patients), bi temporal spikes (1 Patient) and burst suppression pattern (1 Patient). Two Patients (32%) died and one Patient was discharged in bedridden state. Conclusion: The involvement of brain and spinal cord is uncommon in dengue viral infection. Most Patient present with seizures. Neuroirnaging features are diverse. Prognosis is poor in Patients presenting with encephalitis or myelitis

Identification of antiplatelet and acetylcholinesterase inhibitory constituents in betel nut.

Objective: To investigate the possible mechanism and the compound(s) responsible for the antiplatelet and acetylcholinesterase (AChE) inhibitory effects of Areca catechu crude extract (Ac.Cr). Methods: Aqueous-methanol (70%) was used for extraction of plant material (betel nut). Antiplatelet activity was measured in human platelet-rich plasma by using a Lumi-aggregometer while anti-AChE activity was measured spectrophotometrically in vitro. In an attempt to find the responsible compound(s) in betel nut for antiplatelet and anti-AChE activities, different commercially available betel nut compounds were tested. Results: Ac.Cr inhibited platelet aggregation induced by arachidonic acid (AA), adenosine diphosphate (ADP), platelet-activating factor (PAF), epinephrine and Ca(2+)-ionophore. Ac.Cr was the most potent in inhibiting ADP- and Ca(2+)-ionophore-induced aggregation. In the AChE assay, Ac.Cr showed significant AChE inhibitory activity with almost complete inhibition of the enzyme. Out of the tested compounds, none of the compounds in betel nut showed any antiplatelet effect except for catechin that was the most potent against epinephrine-induced aggregation. Catechin was significantly less potent than Ac.Cr, indicating a presence of additional compound(s) with antiplatelet activity. For the AChE inhibitory effect, only tannic acid, gallic acid, diosgenin and isoguvacine were found to be active, whereby tannic acid was more potent than Ac.Cr. Conclusion: This study shows the possible antiplatelet and AChE inhibitory potential of betel nut while further studies are needed to confirm and identify more compounds in betel nut for these actions

Risk factors predisposing to congenital heart defects

Introduction: Congenital heart disease (CHD) is associated with multiple risk factors, consanguinity may be one such significant factor. The role of consanguinity in the etiology of CHD is supported by inbreeding studies, which demonstrate an autosomal recessive pattern of inheritance of some congenital heart defects. This study was done to find out the risk factors for CHD. Methods: A case-control study was done on pediatric Patients at a tertiary care hospital, Aga Khan University Hospital, located in Karachi, Pakistan. A total of 500 Patients, 250 cases and 250 controls were included in the study. Results: Amongst the 250 cases (i.e. those diagnosed with CHD), 122 Patients (48.8%) were born of consanguineous marriages while in the controls (i.e. non-CHD) only 72 Patients (28.9%) showed a consanguinity amongst parents. On multivariate analysis, consanguinity emerged as an independent risk factor for CHD, adjusted odds ratio 2.59 (95% C. I. 1.73 - 3.87). Other risk factors included low birth weight, maternal co-morbidities, family history of CHD and first born child. On the other hand, medications used by the mother during the index pregnancy, maternal age and gender of the child did not significantly increase the risk of developing CHD. Conclusions: Analyses of our results show that parental consanguinity, family history of CHD, maternal co-morbidities, first born child and low birth weight are independent risk factors for CHD