Giant congenital nevus

A 17-year-old boy presented with painful swelling of the front of his chest after a roadside brawl. He had been born with a birthmark on his chest that had grown steadily to its present size. We noted a giant (32-by-21-cm), circular, well-defined, spongy, hairy, jet-black congenital melanocytic nevus occupying the lower chest and epigastrium (Panel A). The nevus was warm to the touch and mildly tender. Multiple satellite lesions over the trunk, face, limbs, palms, and lower back (Panel B, arrow) were present. No neurologic deficits were identified. Congenital nevi, which are benign proliferations of melanocytes in the dermis, epidermis, or both, occur in 1 to 2% of newborn infants. If the nevus is greater than 20 cm in diameter, it is classified as giant. Satellite lesions are often found in patients with giant congenital nevi. Giant congenital nevi may cause cosmetic problems, undergo malignant transformation, or be a part of the rare syndrome of neurocutaneous melanosis, which is characterized by congenital melanocytic nevi and melanotic neoplasms of the central nervous system. The patient's symptoms improved with oral antibiotic therapy. Despite discussion of the risk of subsequent melanoma, the patient and his parents declined surgical resection of the giant nevus

Inadequate inhaler technique, an everlasting problem, is associated with poor disease control – A cross sectional study

Introduction: Dry powder inhalers (DPI) have been in use in the treatment of chronic respiratory diseases for decades. DPIs require proper inhaler technique to ensure appropriate dose delivery to the lungs which in turn provides disease control and hence reduces the economic burden due to frequent acute attacks and hospital visits. Inadequate inhaler technique remains an everlasting problem among patients with chronic respiratory disease. Hence the aim is to assess the inhaler technique in patients using DPI and to determine the factors associated with inhaler technique.Material and methods: A cross-sectional study was conducted and 385 patients with asthma or chronic obstructive pulmonary disease (COPD) were recruited. Patient-related and disease-related factors were noted. Severity of the disease were assessed using asthma control test/COPD assessment test questionnaire and spirometer. The investigator assessed the inhaler technique of the patient against standard checklist.Results: Nearly 46.2% of the patients performed incorrect inhaler technique. Multivariate analysis showed factors like young age [Odd’s ratio (OR) 4.13, CI 1.31–17.8], well controlled disease (OR 2, CI 1.1–3.65), and the patients who learnt the technique from a medical personnel (OR 3.67, CI 1.46–9.24) had better inhaler technique.Conclusion: This study shows that the proper use of inhaler is still an unattained goal and significance of correct use has to bereiterated

Association of Intracellular TH1-TH2 Balance in CD4+ T-cells and MIP-1α in CD8+ T-cells with Disease Severity in Adults with Dengue

Background: We tested the hypothesis that dengue haemorrhagic fever (DHF) is associated with a TH1-skewed immune response as opposed to dengue fever (DF). Methods: We estimated intracellular (in T-cells) and serum levels of designate TH1/TH2 cytokines [interferon-γ (IFN-γ), interleukin-4 (IL-4), and tumor necrosis factor-α] and macrophage inflammatory protein-1α (MIP-1α) at admission, 48 h, and day 5 in 20 adults with dengue (DF=10, DHF=10) and 10 dengue-naive healthy controls. Results: At admission, intracellular IFN-γ/IL-4 ratio in CD4+ T-cells and proportion of MIP-1a-positive CD8+ T-cells were significantly higher in patients with DHF [7.21 (5.36 ~ 10.81) vs. 3.04 (1.75 ~ 4.02); p=0.011 and 6.2% (3.2 ~ 8.2%) vs. 2.4% (2.0 ~ 3.6%); p=0.023]. The latter showed a significant positive correlation with IFN-γ/IL-4 ratio in CD4+ T-cells (Spearman's rho=0.64; p=0.003), percentage-change in haematocrit (rho=0.47; p=0.048), and serum alanine aminotransferase level (rho=0.61; p=0.009). Conclusion: We conclude that DHF is associated with a TH1-skewed immune response. Further, MIP-1α in CD8+ T-cells is an important immunologic correlate of disease severity in dengue

Spectrum of clinical disease in a series of 135 hospitalised HIV-infected patients from north India

BACKGROUND: Literature on the spectrum of opportunistic disease in human immunodeficiency virus (HIV)-infected patients from developing countries is sparse. The objective of this study was to document the spectrum and determine the frequency of various opportunistic infections (OIs) and non-infectious opportunistic diseases, in hospitalised HIV-infected patients from north India. METHODS: One hundred and thirty five consecutive, HIV-infected patients (age 34 ± 10 years, females 17%) admitted to a tertiary care hospital in north India, for the evaluation and management of an OI or HIV-related disorder between January 2000 and July 2003, were studied. RESULTS: Fever (71%) and weight loss (65%) were the commonest presenting symptoms. Heterosexual transmission was the commonest mode of HIV-acquisition. Tuberculosis (TB) was the commonest OI (71%) followed by candidiasis (39.3%), Pneumocystis jiroveci pneumonia (PCP) (7.4%), cryptococcal meningitis and cerebral toxoplasmosis (3.7% each). Most of the cases of TB were disseminated (64%). Apart from other well-recognised OIs, two patients had visceral leishmaniasis. Two cases of HIV-associated lymphoma were encountered. CD4+ cell counts were done in 109 patients. Majority of the patients (82.6%) had CD4+ counts <200 cells/μL. Fifty patients (46%) had CD4+ counts <50 cells/μL. Only 50 patients (37%) received antiretroviral therapy. Twenty one patients (16%) died during hospital stay. All but one deaths were due to TB (16 patients; 76%) and PCP (4 patients; 19%). CONCLUSIONS: A wide spectrum of disease, including both OIs and non-infectious opportunistic diseases, is seen in hospitalised HIV-infected patients from north India. Tuberculosis remains the most common OI and is the commonest cause of death in these patients

Clinical outcomes in typhoid fever: adverse impact of infection with nalidixic acid-resistant Salmonella typhi

BACKGROUND: Widespread use of fluoroquinolones has resulted in emergence of Salmonella typhi strains with decreased susceptibility to fluoroquinolones. These strains are identifiable by their nalidixic acid-resistance. We studied the impact of infection with nalidixic acid-resistant S. typhi (NARST) on clinical outcomes in patients with bacteriologically-confirmed typhoid fever. METHODS: Clinical and laboratory features, fever clearance time and complications were prospectively studied in patients with blood culture-proven typhoid fever, treated at a tertiary care hospital in north India, during the period from November 2001 to October 2003. Susceptibility to amoxycillin, co-trimoxazole, chloramphenicol, ciprofloxacin and ceftriaxone were tested by disc diffusion method. Minimum inhibitory concentrations (MIC) of ciprofloxacin and ceftriaxone were determined by E-test method. RESULTS: During a two-year period, 60 patients (age [mean ± SD]: 15 ± 9 years; males: 40 [67%]) were studied. All isolates were sensitive to ciprofloxacin and ceftriaxone by disc diffusion and MIC breakpoints. However, 11 patients had clinical failure of fluoroquinolone therapy. Infections with NARST isolates (47 [78%]) were significantly associated with longer duration of fever at presentation (median [IQR] 10 [7-15] vs. 4 [3-6] days; P = 0.000), higher frequency of hepatomegaly (57% vs. 15%; P = 0.021), higher levels of aspartate aminotransferase (121 [66–235] vs. 73 [44–119] IU/L; P = 0.033), and increased MIC of ciprofloxacin (0.37 ± 0.21 vs. 0.17 ± 0.14 μg/mL; P = 0.005), as compared to infections with nalidixic acid-susceptible isolates. All 11 patients with complications were infected with NARST isolates. Total duration of illness was significantly longer in patients who developed complications than in patients who did not (22 [14.8–32] vs. 12 [9.3–20.3] days; P = 0.011). Duration of prior antibiotic intake had a strong positive correlation with the duration of fever at presentation (r = 0.61; P = 0.000) as well as the total duration of illness (r = 0.53; P = 0.000). CONCLUSION: Typhoid fever caused by NARST infection is associated with poor clinical outcomes, probably due to delay in initiating appropriate antibiotic therapy. Fluoroquinolone breakpoints for S. typhi need to be redefined and fluoroquinolones should no longer be used as first-line therapy, if the prevalence of NARST is high

Spontaneous splenic rupture in dengue hemorrhagic fever

A 29-year-old woman was admitted with a 7-day history of fever, myalgia, and headache. She had had recurrent melena since the third day of illness. She was febrile and anicteric. No rash or lymphadenopathy was evident, and a tourniquet test was negative. Mild hepatomegaly and shifting abdominal dullness were present. The neck was supple with no neurologic deficit. Platelet count was 90,000/µL, and hematocrit was 33%. A peripheral blood smear did not show malarial parasites, and blood cultures were sterile. Dengue virus-specific IgM antibodies were found to be positive. On Hospital Day 3, the patient had a sudden onset of abdominal pain and distension; hematocrit dropped to 15%. Paracentesis yielded frankly hemorrhagic fluid with a hematocrit of 11%. Contrast-enhanced computed tomography showed ascites (Figure 1A, asterisks) and an organized, non-enhancing collection over the posterosuperior aspect of spleen, suggestive of splenic rupture with adherent thrombus (Figure 1A, arrow); bilateral pleural effusions (Figure 1B, arrows) were also evident. She was managed conservatively with packed red cell transfusions and crystalloids. Over the next few days, hemoperitoneum and pleural effusions resolved uneventfully. Spontaneous splenic rupture is a well-known complication of acute infections such as malaria and infectious mononucleosis; nonetheless, it is rarely reported in dengue hemorrhagic fever

Medical management of genitourinary tuberculosis

Antimycobacterial chemotherapy is the mainstay of treatment for the majority of patients with genitourinary tuberculosis (GUTB). A large body of evidence from clinical trials suggests that short-course chemotherapy regimens, employing four drugs including rifampicin and pyrazinamide, achieve cure in most of the patients with tuberculosis (TB) and are associated with the lowest rates of relapse. Standard six-month regimens are adequate for the treatment of GUTB. Directly observed treatment, short-course (DOTS) is the internationally recommended comprehensive strategy to control TB, and directly observed treatment is just one of its five elements. DOTS cures not only the individual with TB but also reduces the incidence of TB as well as the prevalence of primary drug-resistance in the community. Corticosteroids have no proven role in the management of patients with GUTB. Errors in prescribing anti-TB drugs are common in clinical practice. Standardized treatment regimens at correct doses and assured completion of treatment have made DOTS the present-day standard of care for the management of all forms of TB including GUTB

Inadequate Inhaler Technique, an Everlasting Problem Associated with Poor Disease Control—A Cross-Sectional Study

Introduction: Dry powder inhalers (DPI) have been in use in the treatment of chronic respiratory diseases for decades. DPIs require proper inhaler technique to ensure appropriate dose delivery to the lungs which in turn provides disease control and hence reduces the economic burden due to frequent acute attacks and hospital visits. Inadequate inhaler technique remains an everlasting problem among patients with chronic respiratory disease. Hence the aim is to assess the inhaler technique in patients using DPI and to determine the factors associated with inhaler technique. Material and methods: A cross-sectional study was conducted and 385 patients with asthma or chronic obstructive pulmonary disease (COPD) were recruited. Patient-related and disease-related factors were noted. Severity of the disease were assessed using asthma control test/COPD assessment test questionnaire and spirometer. The investigator assessed the inhaler technique of the patient against standard checklist. Results: Nearly 46.2% of the patients performed incorrect inhaler technique. Multivariate analysis showed factors like young age [Odd’s ratio (OR) 4.13, CI 1.31–17.8], well controlled disease (OR 2, CI 1.1–3.65), and the patients who learnt the technique from a medical personnel (OR 3.67, CI 1.46–9.24) had better inhaler technique. Conclusion: This study shows that the proper use of inhaler is still an unattained goal and significance of correct use has to be reiterated