A rare clinical case of subdural hemorrhage in a patient with scrub typhus

Scrub typhus is a common infectious disease with a self-limiting course but may potentially cause a fatal outcome in some cases. We here present a case report of a patient diagnosed with scrub typhus and was given effective antibiotic therapy. Initially, the patient improved significantly but had sudden clinical deterioration on day five and presented with subdural hemorrhage. Orientia tsutsugamushi the causative agent of scrub typhus may be considered as a causal or provoking factor for cerebrovascular accidents in regions where scrub typhus is endemic. Patients should be followed strictly during convalescence in such cases especially in those who have received delayed treatment

Metformin induced yellow nails: a rare entity

This article reports an interesting and a rare case of metformin induced nail disorder in a middle aged female with type 2 diabetes. The patient had been receiving metformin one 1500mg daily from the last 6 months and noticed her finger nails gradually thickened and turned yellow. On stopping the metformin, the nails gradually normalized. The patient was treated further with glimepiride and insulin glargine. After 3 months of discontinuation of metformin there was a significant improvement in the nails. Clinicians should be aware of metformin induced yellow discolouration of nails, though a curable and reversible condition if diagnosed well in time

An unusual case of trifluoperazine induced hypoglycemia

Hypoglycemia is a serious condition which if not diagnosed and treated urgently may cause irreversible damage to the brain and may be life threatening. There are various causes attributed to hypoglycemia, but drugs are one of the most important one of them. Various drugs are documented to cause hypoglycemia but we present a rare case report of a 52-year-old male patient with schizoaffective disorder on trifluoperazine who presented in emergency department with documented hypoglycemia and this hypoglycemic episode improved when the drug was withdrawn. When WHO causality assessment scale was applied, trifluoperazine was found as the probable cause of the episodes of hypoglycemia. Therefore, this possibility of hypoglycemia should always be kept in mind while prescribing trifluoperazine

Escitalopram induced syndrome of inappropriate antidiuretic hormone in elderly: an interesting scenario

Selective serotonin reuptake inhibitors (SSRI) are the first line drugs used in the treatment of endogenous depression. Though clinically well tolerated in elderly, hyponatremia is one of the recognized side effects and its pathophysiology may be linked to syndrome of inappropriate antidiuretic hormone (SIADH). This side effect of SSRIs is a serious one since it can cause death also, if not diagnosed at the onset.  This is an interesting case of an elderly patient who developed hyponatremia which further related to SIADH induced by escitalopram, an SSRI.  The patient had symptomatic improvement in depression within one month but symptoms of hyponatremia appeared and then deteriorated again. Severe hyponatremia, serum hypo-osmolality, urine osmolality, and measurable levels of plasma antidiuretic hormone suggested SIADH. The hyponatremia improved after stoppage of the offending drug along with conservative medical therapy in hospital.  Clinicians should be aware of this uncommon but significant side effect of escitalopram and monitor high-risk patients for the development of SIADH

Pattern of adverse drug reactions in new smear positive patients of pulmonary tuberculosis treated under directly observed treatment short course

Background: Directly observed treatment short course (DOTS), a combination therapy, drugs are administered for six to eight months in patients diagnosed with tuberculosis, increases the risk of adverse drug reactions. The objective of this study was to study the adverse drug reaction profile of new sputum smear positive (NSP) patients of pulmonary tuberculosis (PTB) treated under DOTS. A prospective observational study was carried out in Dr. RPGMC Kangra at Tanda, Himachal Pradesh, India over a period of six months.Methods: The study included 130 newly diagnosed TB patients on anti‑TB treatment under DOTS. A symptom based approach was followed for monitoring ADRs. The severity was assessed by Modified Hartwig scale and causality by WHO-UMC probability scale. Data was expressed as percentages for discrete variables using Microsoft excel.Results: Out of the total 130, 84 patients experienced ADRs with an overall incidence of 64.6%. 45 (34.6%) patients showed single ADR whereas 39 (30%) patients had two or more ADRs. Gastritis alone was present in 36 (27.8%) patients followed by itching 2 (1.5%), hypersensitivity 2 (1.5%), arthralgia 2 (1.5%), generalized weakness 2 (1.5%) and jaundice in 1 (0.8%) patients. Vomiting was present in 29 (22.2%) patients, neuropathy in 4 (3.1%) patients, arthralgia in 2(1.5%) patients, hypersensitivity, jaundice, itching and generalized weakness in 1 (0.8%) patient each. 21 (16.2%) patients experienced mild , 56 (43.1%) had moderate and only 7 (5.4%) had severe ADRs. All the ADRs were possible in nature.Conclusions: The incidence of ADRs was 64.6% and GI irritation was found to be most common ADR reported by 57.6% patients

Snakebite presenting as acute coronary syndrome: An interesting diagnosis and management

Snakebite is a common presentation in India, especially in the Sub-Himalayan region. The most common presentation of snakebiteis neurotoxic and hematologic complications. Acute coronary syndrome after a snakebite is rare. This case report explicitly explainsa patient presenting as acute coronary syndrome after a snakebite with dynamic electrocardiogram changes. Later on, the anti-snakevenom therapy was given to the patient and her condition improved. It should be kept in mind that, since the pathology of snakebiteinducedmyocardial infarction is different, its management will also be different

Saxagliptin induced bilateral knee arthralgia: a rare case report

A 55 year old female patient of type 2 diabetes mellitus on saxagliptin (5 mg once a day), a dipeptidyl peptidase 4 inhibitor (DPP-4 inhibitors) as add on therapy to metformin (1000 mg twice a day). After two months of addition of saxagliptin, the patient had pain in both the knee joints. Saxagliptin was withdrawn and then the knee pain was gradually relieved. Other cause of joint pains like osteoarthritis, rheumatoid arthritis, gout, septic arthritis etc. were ruled out. We consider that this case is important in bringing this potential side effect to the attention of both pharmacologists and primary care physicians as DPP- IV inhibitors has been the most commonly used drug substitute to glimepiride as an add on therapy to metformin

Liver cirrhosis first time presented with delirium unveiled as accidental secondary hypothermia

Liver cirrhosis is a condition which is defined histopathologically but cannot be diagnosed clinically without any non-invasive tests. There are various etiologies of cirrhosis such as alcoholic liver disease, chronic viral hepatitis B, C, and non-alcoholic fatty liver diseases. Liver, not only function as an organ for detoxification, conjugation, and synthesis but also it regulates body heat. Cirrhosis patients thus are prone to body heat loss and hyperthermia. We present a case with undiagnosed liver cirrhosis patient, 1st time presenting with altered sensorium, revealed as accidental secondary hypothermia with ECG changes of hypothermia. The patient treated for hypothermia only after which she recovered

Profile of adverse drug reactions in patients on anti-tubercular drugs in a sub Himalayan rural tertiary care teaching hospital

Background: Tuberculosis is a major public health problem, with one out of three people in the world are infected with Mycobacterium tuberculosis. The prevalence of MDR TB in India is 2-3% among new cases and 12-17% in reinfection cases. One of the reasons for MDR may be noncompliance to treatment due to adverse drug reactions. The present study was conducted to find out ADRs in patients on antitubercular treatment (ATT) under pharmacovigilance programme of India (PvPI).Methods: This was a retrospective observational study. Data was collected through voluntary reporting by health-care professionals (HCP) in standard IPC-PvPI prescribed suspected ADR reporting form and analyzed for 100 patients on ATT. Causality assessment was done using WHO causality assessment scale.Results: The maximum ADRs were reported in adults with a mean age of 40.79±16.79 years. Males (n=66) outnumbered females (n=34). There were 62% MDR-TB on DOTS-plus regimen, followed by 35% on Cat1 ATT for pulmonary and extrapulmonary tuberculosis cases and XDR-TB accounted for 3% of the total cases. The commonest ADRs in patients on MDR treatment were related to CNS 44 (27.5%), followed by Gastrointestinal system 31 (19%), psychiatric 20 (12.5%) otovestibular 13 (8%) and ophthalmic ADRs being the least in frequency 1 (0.6%). In contrast patients on Cat 1 ATT the ADRs involving Gastrointestinal system 44 (44%) followed by CNS 12 (12%), psychiatric 0% and ADRs related to otovestibular manifestations being the least 1 (1%) frequency.Conclusions: ADRs involving different organ systems were seen in both categories with varied frequency. Adverse drug reactions add to hospitalization expenses, insurance costs and increase in work loss days besides addition to patient suffering and loss of compliance. Prior knowledge can help in better prescriptions and prevent valuable resource loss