Atraumatic splenic rupture associated with apixaban.

Apixaban is a direct oral anticoagulant that works by inhibiting factor Xa. It has been associated with adverse bleeding outcomes including atraumatic splenic rupture. We present the case of an 86-year-old man who presented with features of left upper abdominal pain and hemorrhagic shock found to have atraumatic splenic rupture and hemoperitoneum on imaging

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A histopathological study of granulomatous lesions

Background: Granulomas are the commonest lesions that the pathologists come across in routine practice. Granulomatous inflammation is a special type of chronic inflammation that is a manifestation of many infective, toxic, allergic, autoimmune and neoplastic diseases and also conditions of unknown etiology. The aim of this study is to analyze different granulomatous lesions and to find the frequency and etiology of all granulomatous lesions.Materials and Methods: The study included a total of 218 granulomatous lesions, received over a period of one year from July 2013 to June 2014 in the department of pathology, TUTH. Special stains like Ziehl-Neelsen, PAS and Wade- Fite- Faraco were done whenever required.Results: Granulomatous lesion accounted for 3% of all biopsies. The median age of the patients was 29 years and the majority of the patients were in the age group of 20-29 years with no sex predilection. Majority of granulomas were seen in lymph nodes (32.1%), followed by skin and subcutis (29.4%), and bones and joints (11%). Tuberculosis was the most common cause of granuloma with 143 (65.6%) cases, followed by leprosy, foreign body and fungal infection. The most common type of granuloma was epithelioid (87.2%), followed by epithelioid with suppuration, histiocytic, foreign body and mixed inflammatory.Conclusion: The granulomatous lesion is common in third decade of life with no sex predominance. The commonest site is lymph node with tuberculosis being the most common cause followed by leprosy. The epithelioid type was the most common type of granuloma.</p

Pelvic Lymphocele: An Obscure Cause of Unilateral Leg Swelling

Case Presentation: A 57-year-old man with robotic prostatectomy 2 months ago for prostate cancer presented with 2 days of right lower extremity swelling. His history was notable for a large right lower extremity deep vein thrombosis (DVT) for which he had an IVC filter placed, and pulmonary embolus for which he was on rivaroxaban. He denied fever, chills, joint pain, muscle aches, recent trauma or falls. On examination, he had uniform non- pitting edema of the right lower extremity from ankle to thigh, without associated tenderness, deformity or skin changes. Right lower extremity pulses and sensation were intact. He was afebrile without leukocytosis. Ultrasound of the right lower extremity revealed no evidence of acute DVT, and resolution of the previous thrombus. CT scan of abdomen and pelvis identified a right groin lymphocele that was compressing the right iliac vein. Interventional radiology placed a percutaneous drain and the patient was discharged home. On follow up, his swelling had significantly improved and as there was no further drainage, the percutaneous catheter was removed. Discussion: Unilateral leg swelling is commonly encountered and poses a diagnostic challenge. Acute unilateral lower extremity swelling is usually due to DVT or trauma, whereas lymphedema and venous insufficiency are common causes of chronic swelling. Lymphocele formation that leads to major complications after radical prostatectomy is rare, and is usually seen in the early postoperative period. However, it should be considered in patients with fever, abdominal pain or leg swelling during the late postoperative period in patients who underwent extensive lymph node dissection. Surgical treatment options are available, but percutaneous intervention is preferred. Conclusions: Pelvic lymphocele, a collection of lymphatic fluid that develops after extensive lymphadenectomies, is not an infrequent complication after radical prostatectomy and pelvic lymphadenectomy occurring in 20% of cases. Rarely pelvic lymphocele may cause unilateral leg swelling due to its mass effect causing a diagnostic dilemma

Gabapentin Induced Anasarca in a Young Patient: An Under-Recognized Side Effect of a Common Medication

Case Presentation: 47-year-old male presented with complaint of generalized body swelling after three days of starting Gabapentin therapy (600 mg twice daily). Lower extremity edema gradually progressed to abdomen and upper extremity within this short duration. He denied trauma, insect bites, prior blood clots, chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, anorexia, skin changes, dysuria, frothy urine, blood in urine or use of any herbal supplements. Vitals stable. On exam, 3+ pitting edema present extending up-to upper extremity. Chest, cardiovascular and neurological exam were benign. No stigmata of chronic liver disease were seen. Complete blood count, metabolic panel, liver function, albumin, brain natriuretic peptide, thyroid stimulating hormone and random cortisol were within normal range. Echocardiogram revealed ejection fraction of 75 %, normal diastolic function and normal pulmonary artery pressure. Urinalysis was negative for bacteria, leukocytes, casts or protein. CT abdomen and ultrasound doppler lower extremities unremarkable. Gabapentin was discontinued, and his peripheraledema dramatically improved over the next few days with leg elevation, compression stockings and intravenous Furosemide. Discussion: Data published on gabapentin associated edema is very scarce and exact mechanism is unclear. Our casehighlights the three important points in association with gabapentin use. 1. occurrence of this rare side effect in a young adult 2. side effects noted at lower dose than reported in the literature 3. more severe form of generalized edema rather than localized lower extremity edema Conclusions: Gabapentin is a relatively safe drug frequently prescribed as an analgesic, antiepileptic and even used for multiple psychiatric conditions. Gabapentin associated bilateral pedal edema is rather an uncommon adverse effect reported at doses higher than 1200 mg/day mostly in geriatric population (7-7.5%). Recognition of this entity is crucial, especially in the presence of confounding factors such as heart failure, nephrotic syndrome and others as discontinuation of Gabapentin leads to full recovery

A Comparative Study between Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis in a Tertiary Care Center of Nepal

Background: Laparoscopic Cholecystectomy is considered as a gold standard treatment for symptomatic cholelithiasis. The timing of surgery for acute Cholecystitis is still controversial, weather to go early surgery or wait for six to eight weeks after conservative management. Therefore, the aim of this study is to compare the clinical outcomes of early versus delayed laparoscopic cholecystectomy for acute Cholecystitis. Materials and Methods: A prospective study was conducted in Nobel Medical College Teaching Hospital, Biratnagar, Nepal. Total of 80 patients with the diagnosis of acute Cholecystitis were enrolled in the study. The patients were equally divided in two groups: 40 underwent early laparoscopic cholecystectomy within 72 hours of admission (Group A) and next 40 underwent delayed laparoscopic cholecystectomy after 6-8 weeks of conservative management (Group B). Results: Out of 80 patients of acute Cholecystitis, mean age of the patients in Group A was 43.40±13.45 years and that in Group B was 44.80±14.36 years. The mean operative time in Group A was 90.22±2.81 minutes whereas in Group B it was 80.97±4.47 minutes. Mean duration of Hospital stay in Group A was 2.02±0.15 days whereas in Group B it was 2.15±0.36 days. Two patients in Group A and one patient in Group B converted to open cholecystectomy. Three patients of Group A and one patient of Group B landed in outpatient department with superficial surgical site infection.  Group B patients underwent second hospital admission compared to Group A patients. Conclusion: Early Laparoscopic cholecystectomy for acute cholecystitis is almost comparable with delayedLaparoscopic cholecystectomy. However, early laparoscopic cholecystectomy reduces the morbidity of patients as well as it is cost-effectiveness

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19

International audienc