TB myositis in a patient with dermatomyositis post immunosuppression

55-year-old African female with a history of initially refractory TIF1-y antibody positive dermatomyositis, with progressive proximal muscle weakness with difficulty swallowing, requiring regular inpatient admissions with the administration of IV steroids and IVIG. The patient was started on immunosuppression with mycophenolate as a steroid sparing agent. The patient slowly improved after initiation of immunosuppression, with a significant reduction in her rash, weakness, and dysphagia. After a few months of therapy, the patient noted pain in the right axilla and proximal right lower extremity with swelling and pain limiting her mobility. There was a concern for underlying malignancy for which PET scan was done, which showed hypermetabolic edema and swelling of musculature involving right thigh, right pectoral minor and left scapularis consistent with infectious or inflammatory myositis. Concern for focal dermatomyositis was raised and the patient received pulse IV steroids over 5 days with initial improvement. The patient later developed fevers, night sweats and chills, for which the patient was seen in ED. Initial vitals were concerning for sepsis, due to which patient was started on broad-spectrum antibiotics. CT scan of the chest and right lower extremity were done which showed, no pulmonary infiltrates, 5 cm right pectoralis minor and 9.4 cm right gluteus minimus fluid collection consistent with abscess.Interventional radiology was consulted, and abscesses were aspirated, aspirate from chest wall was positive acid-fast bacilli, concerning for mycobacterium. Cultures were sent to the health department and were noted to be positive for TB. At this time, it was noted that the patient had a prior diagnosis of latent TB when she moved to the United States. The patient was started on Myambutol, Nydrazid, Levaquin, Rifampin, and Bactrim.Tuberculous infections continue to be one of the deadliest infections around the world, with a significantly low incidence rate (2.8/100000) as compared to developing countries. Even with a low incidence rate, there is always a concern for reactivation of latent TB with the initiation of immunosuppression. Tb myositis is one of rare presentation and that can be difficult with diagnosis, especially in a patient who has an underlying autoimmune condition that could have a similar presentation. We recommend getting prior workup to rule out tuberculosis prior to the initiation of immunosuppression

Bilateral Moyamoya Disease in a 2-Year-Old Pakistani Male Treated with Bilateral Encephaloduroarteriosynangiosis: A Positive Outcome.

Background. We present a rare case of bilateral moyamoya disease presenting as multiple strokes and neurological deficits, treated with the neurosurgical procedure, encephaloduroarteriosynangiosis (EDAS), in a 2-year-old male Pakistani minor. A positive outcome was achieved and the patient recovered fully. Case Summary. Our patient presented with a history of seizures and multiple episodes of hemiparesis (on and off weakness) at the age of 2 years. He had a delayed speech development and could not speak more than a few words. He had a slight slurring of speech too. He was diagnosed with bilateral moyamoya disease on Computed Tomography Angiography (CTA). Bilateral EDAS was done in the same year, after which his symptoms improved and patient had moderate functional recovery. Conclusion. A rare disease, moyamoya has been left unexplored in Pakistan; physicians and surgeons when dealing with cases in the pediatric population presenting with symptoms of stroke, signs of generalized weakness, and seizures should consider moyamoya disease as a possibility. Furthermore, this case demonstrates the effectiveness of EDAS procedure for the treatment of moyamoya disease

Variation of Peak Expiratory Flow Rate with Body Mass Index in Medical Students of Karachi, Pakistan

OBJECTIVE: The primary aim of our study was to assess the variation of PEFR with BMI in normal medical students of Karachi, PakistanDESIGN: Cross-sectional studySetting: Medical students of Karachi Medical and Dental CollegeParticipants: 138 non-smoker healthy medical students composed of 111 females and 27 males. VARIABLE PARAMETERS: They include mean age, body height and body weight and PEFR. They were marked separately for each genderRESULTS: The mean BMI in females was found out to be 18.54±2.10 corresponding with that of mean PEFR value 431.62±56.62 whereas in males the mean BMI was 25.07±2.96 corresponding with that of mean PEFR value 533.70±23.22. Also there is a statistically significant variation in PEFR with an increase in BMI.CONCLUSION: The study concludes that PEFR is affected positively by variation in BMI. Also young males have more BMI and PEFR values than their young female counterparts. A large sample size with accurate peak flow meter is required along with ethnic consideration of the study population for better and accurate result