A CLINICAL STUDY OF PATIENTS WITH IDIOPATHIC THROMBOCYTOPENIC PURPURA

OBJECTIVE To study the incidence, age and sex distribution among adults, various modes of presentation, correlation between thrombocytopenia and bleeding manifestations and various modalities of treatment of Idiopathic Thrombocytopenic Purpura in a tertiary care hospital in India.MATERIALS AND METHODSProspective study consisting of 4o cases of ITP admitted to Kasturba Medical College Hospital, Manipal from November 2005 to March 2007. Patients above 14 years of age admitted with thrombocytopenia in this institution were screened based on detailed clinical history, physical examination and laboratory investigations.RESULTSThe maximum incidence was in the 3 rd decade of life accounting for 27.5% of the patients. Ratio of male to female was 1:1.9 with female preponderance. Females in 3 rd decade had maximum incidence while males in 4th decade have maximum incidence. Majority 12 (85.71%) of male patients and 15(57.69%) of female patients  developed purpura during the course of disease. The mean count was 17.8X109/L with range between 2.0 X109/L to 76 X109/L. Cutaneous bleeding spots were found to be assosiated with counts above 25000X109/L and hematuria with lowest counts around 4000 X109/L. 20 (50%) of the above 40 patients responded to corticposteroids alone and did not have any further relapse. Among the remaining patients 3 (7.5%) had a relapse of symptoms within next 6 months and responded to repeat prednisolone started at 1mg/kg. 2 (5%) patients were given steroids tapering dose with IV Immune globulins for initial 5 days as therapy to which they responded.CONCLUSIONIdiopathic thrombocytopenia is 1.9 times more common in females than males. Most common presentation is bleeding spots over body. Bleeding manifestations are more common with thrombocytopenia less than 30000/mm3. Corticosteroids are the mainstay in treatment. Complete remission is seen in up to 57.5% of the patients. Splenectomy is the second modality of treatment in ITP. Complete and sustained remission is seen 75% of patients. Â

ACENOCOUMAROL OR WARFARIN: WHICH IS THE CLINICIAN'S ALLY?

ABSTRACTWarfarin and acenocoumarol are commonly prescribed oral anticoagulant drugs that are used in the prevention and treatment of thromboembolicdisorders across the world. Although both these drugs act by a similar mechanism, there are significant differences between them, especially in termsof their half-lives, and more importantly, in their variability in response pharmacogenetically. This case report highlights an instance wherein warfarinproved to provide a much more stable anticoagulant cover, as compared to that provided by acenocoumarol.Keywords: Thrombosis, Bleeding, Antiphospholipid antibody syndrome, Anticoagulant, International normalized ratio

HEMICHOREA: AN UNUSUAL MANIFESTATION OF THYROTOXICOSIS

ABSTRACTChorea is usually associated with neurological diseases. However, it can also be seen in patients with systemic lupus erythematosus (SLE), rheumaticfever (Sydenham's chorea), polycythemia vera, and thyrotoxicosis. Here, we report an interesting case of hemichorea in a 32-year-old lady, whopresented with acute onset of jerky, non-repetitive involuntary movements of the left upper and lower limbs. After detailed evaluation, she was foundto have thyrotoxicosis. Thyroid Tc-scan showed diffuse uptake suggesting Grave's disease. A magnetic resonance imaging of the brain was normal.Other causes of chorea like SLE and rheumatic fever were excluded. She was started on carbimazole. On follow-up after 6 weeks of therapy, there wasthe complete disappearance of chorea, and her thyroid hormone levels were normal.Keywords: Extrapyramidal syndrome, Hyperthyroidism, Corpus striatum, Dancing movements

HYPOKALEMIC PERIODIC PALSY AS THE PRIMARY PRESENTATION OF SJOGREN'S SYNDROME

ABSTRACTThe most common presentations of Sjogren's syndrome include dryness of eyes, oral cavity, and features of systemic scleroderma. When a patientwalks in with such classical features, it becomes easy for the clinician to diagnose and treat the patient. However, Sjogren's syndrome may presentatypically as experienced in the present case. Here, the authors present a case of Sjogren's syndrome, which presented as hypokalemic periodic palsy,secondary to distal renal tubular acidosis.Keywords: Scleroderma, Potassium, Sicca syndrome, Renal tubular acidosis

PHENYTOIN-INDUCED ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS

ABSTRACTPhenytoin is the first line antiepileptic for generalized tonic-clonic seizures. It is still the go to†drug despite the availability of newer antiepileptics,chieflybecause of its lowcost and highefficacy.Phenytoinis associatedwith toxicitiesinvolvingmultiple organsystemssuch asbrain,blood, and skin. One of the most common adverseeffectsis the developmentof skin rashes.It can rangefrommild tolife-threateningskineruptions.This is a case reportof a younggirlwhodevelopedacutegeneralizedexanthematouspustulosis followingphenytointherapyforposttraumaticseizures.Keywords: Drug-induced rash, Anti-epileptic, Type-4 hypersensitivity, Hydantoi

THORACIC EPIDURAL ABSCESS DUE TO COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

ABSTRACTA spinal epidural abscess threatens the spinal cord or cauda equina by compression and also by vascular compromise. If left untreated, an expandingsuppurative infection in the spinal epidural space can impinge on the spinal cord, producing sensory symptoms and signs, motor dysfunction, andultimately paralysis, followed by death. Hence, early intervention undoubtedly improves the outcome. The authors report a case of a 27-year-oldfemale patient, who presented with paraplegia, and was found to have thoracic epidural abscess due to community-acquired methicillin-resistantStaphylococcus aureus.Keywords: Spinal cord, Cauda equina, Infection, Laminectomy, Drainage

CLINICAL AND BIOCHEMICAL PROFILE OF STEROID-INDUCED DIABETES

ABSTRACTObjective: To study the clinical and biochemical profile of patients who develop steroid-induced diabetes (SID) and its predisposing factors.Methods: Non-diabetic patients aged ≥18 years started on steroids were considered eligible for the study. In every case after detailed examination,fasting plasma glucose (FPG), post-prandial plasma glucose (PPG), glycated hemoglobin, fasting insulin were measured prior to starting steroids andwas repeated in 1 week (day 3/4) after starting steroid according to standard guidelines. FPG and PPG were repeated periodically during follow-upof the patients. The utility of Indian diabetic risk score (IDRS) score in predicting the risk for SID was also assessed.stResult: Steroid-induced diabetes was found to be more in females than in males. IDRS is not useful in predicting the risk factors of SID. 97% of patientshad an elevation of post-prandial sugars with or without fasting hyperglycemia, but only 3% of patients had isolated elevation of fasting blood sugar.84% of patients developed SID during the 1 week of therapy. 33% of the cases SID persisted even after 1 month of stopping steroids and on a minimaldosage of steroids.stConclusion: Unlike type 2 diabetes, there were no significant risk factors such as age, family history of diabetes to develop SID and IDRS may not be asensitive tool for predicting risk factors of SID. Monitoring of post-prandial sugars as compared to fasting sugars is essential for the screening of SID.Cumulative dose of steroid may not be important to precipitate steroid diabetes.Keywords: Glucocorticoids, Diabetes, Post-prandial glucose, Indian Diabetic Risk Score

BRONCHOCONSTRICTION SECONDARY TO USE OF TOPICAL TIMOLOL IN A NON-ASTHMATIC PATIENT

Ophthalmic application of a non-selective beta blocker like timolol maleate is known to produce bronchoconstriction in asthmatic individuals or patients with obstructive lung diseases. Timolol-induced bronchoconstriction in a previously healthy young adult without any pulmonary disease is rare. We report a case of a young adult who developed bronchoconstriction following ocular instillation of timolol maleate ophthalmic solution when he was treated for open-angle glaucoma

A RARE CAUSE OF SEPTIC ARTHRITIS WITH PLEURAL EFFUSION: BURKHOLDERIA PSEUDOMALLEI

Melioidosis is a fatal disease, most prevalent in South-East Asia, Northern Australia, and the Indian subcontinent is caused by Gram-negative saprophyte Burkholderia pseudomallei. Septic arthritis due to melioidosis is very rare and should be a differential diagnosis in patient presenting with septic arthritis in endemic areas. It results in severe morbidity. Hence, we report a case of septic arthritis of left knee and hip in a young patient who later developed pleural effusion caused by B. pseudomallei.Keywords: Septic arthritis, Pleural effusion, Vietnamese bomb.Â

A RARE INSTANCE OF DIASTASE/PEPSIN–INDUCED HYPERSENSITIVITY REACTION

Diastase/Pepsin combination supplements are very commonly prescribed in clinical practice, mainly in the adult population. The chief indication for such use is indigestion or dyspepsia, wherein concomitant medication with proton pump inhibitors and antiemetics is also advised. Hypersensitivity reactions, though theoretically plausible with the use of digestive enzymes, there are no cases reported in the medical literature, to the best of our knowledge. This is one such case of hypersensitivity secondary to the administration of digestive enzymes in an adult Indian male. Keywords: Digestive enzymes, Rash, Maculopapular, Allerg