The pattern of mucocutaneous infections and infestations in renal transplant recipients

Immunosuppression-related mucocutaneous lesions are a significant problem in renal transplant recipients. Infections account for the majority of these manifestations. The aim of this study was to determine the spectrum of mucocutaneous infections and infestations in renal transplant recipients. Over a period of three years, all the renal transplant recipients presenting with mucocutaneous lesions (only with infectious etiology) were included in the study. Diagnosis was based on the clinical appearance and appropriate investigations like scraping for KOH, Tzanck smear, cultures, and skin biopsies whenever necessary. In order to study the temporal effect of immunosuppression on these mucocutaneous infections, the patients were divided into six groups -with durations of graft survival ranging from 0-2, 2-6, 6-12, 12-24, 24-60, and more than 60 months in Groups A-F, respectively. A total of 104 renal transplant recipients presented with 117 infections and infestations. The mean age at presentation was 35.9 +/- 1.2 years (15-65 yrs), and the mean duration after the transplant was 23.3 +/- 3.5 months (1-175). The mean serum creatinine level at the time of clinical presentation was 1.4 +/- 0.07 mg/dl (0.7-6). Twenty-seven patients were on a two-drug regimen, prednisolone and azathioprine, and the rest were on a three-drug regimen with cyclosporine in addition. Out of the total of 117 infections in 104 patients, 57 were viral, 49 were fungal, and 8 were bacterial. Two patients had scabies and one had cysticercosis. The mean time interval for the occurrence of infections after the transplant was earlier in patients on three-drug immunosuppression (12.4 +/- 2.3 months) than in those on the two-drug regimen (51.3 +/- 1.8 months), (p<0.01). The viral infections had the shortest mean time interval for presentation following transplant, 15.8 +/- 1.2 months (p<0.05). We did not find any statistically significant difference with regard to age or sex of the patients, duration after the transplant, or the pattern of infection. Careful examination of transplant patients is essential for early detection and proper treatment, because the mucocutaneous infections can have atypical morphologies and are likely to become extensive if not treated early.

Efficacy and safety of cyclosporine versus methotrexate in severe psoriasis: a study from north India

Treatment of patients with severe psoriasis is difficult. Among the number of systemic drugs that are available, methotrexate has long been used, but cyclosporine has been recently recommended for the management of severe psoriasis. The purpose of this study was to compare the efficacy and safety of daily cyclosporine with weekly methotrexate in the management of severe psoriasis. Thirty consecutive patients with severe psoriasis were randomly assigned to treatment with cyclosporine or methotrexate. The initial dose of cyclosporine was 3 mg/kg/day, which was increased to a maximum of 4 mg/kg after two weeks of therapy when the response was not adequate. Methotrexate was administered weekly at a dose of 0.5 mg/kg. Clinical response was assessed by calculating PASI score in all patients at biweekly intervals. Patients were followed up fortnightly up to a maximum of 12 weeks. The doses of both drugs were gradually tapered once >75% reduction in disease severity was attained. Marked improvement (>75%) reduction in PASI was noted in all patients except for one in the cyclosporine group. The median time for marked improvement was 5.3 weeks with methotrexate and 6.8 weeks with cyclosporine. Patients on methotrexate were found to have more rapid and complete clearance than those on cyclosporine. Both drugs were well tolerated. Side effects in both the treatment groups were minor, transient, and manageable. At doses with comparable safety profiles, methotrexate resulted in more rapid and cost effective clearance of patients with severe psoriasis. Cyclosporine can provide an effective and safe alternative.

Evaluation of emergency dermatological consultations in a tertiary care centre in North India

INTRODUCTION

The nature of dermatological consultations in an emergency setting has not been studied in detail.

AIM

To evaluate the reasons and the nature of emergency dermatological consultations at a tertiary care centre in India.

MATERIAL AND METHODS

One hundred consecutive emergency calls received over a period of four months from the emergency outpatient department were included in the analysis. The details of all the patients along with their clinical diagnosis were recorded in a proforma. In order to evaluate the reasons for emergency calls they were divided into four categories; Category I comprised of primarily dermatological disorders without any systemic involvement, Category II included III consisted of primarily systemic disorders with related cutaneous lesions and in Category IV systemic diseases with unrelated cutaneous findings were included.

RESULTS

Out of 100 patients, 63 were males and 37 were females. The number of calls in categories I-IV was 57, 9, 7 and 27 respectively. Infections (32) constituted the most common dermatological presentations, followed by drug reactions (27). Only 21 were true dermatological emergencies.

CONCLUSION

Diagnosis and management of common skin diseases should be stressed during the training of physicians in emergency medicine.

FLAIR imaging in the follow-up of low-grade gliomas: time to dispense with the dual-echo?

Fluid-attenuated inversion-recovery (FLAIR) imaging has established its utility in neuroimaging. We propose this imaging sequence as a replacement for proton density (PD) and T2-weighted spin-echo sequences in the follow-up of low-grade glioma. 26 MRI examinations of 18 patients with such tumours were reviewed by three neuroradiologists and a neurosurgeon. FLAIR was found to be superior for appreciation of the lesion (91% of studies) and for demonstration of its margin (92%). FLAIR was also better at showing different tumour components, particularly in regions difficult to demonstrate in some planes, such as the vertex in axial imaging. The sequence also defines the postoperative cavity, shows the least amount of susceptibility effect associated with surgical clips, and demonstrates local spread (to white matter tracts, subependymal and capsular) more distinctly. We conclude that FLAIR can replace PD and T2-weighted spin-echo imaging in radiological follow-up of low-grade glioma.

Unforeseen Intra-operative Hyperkalemia in a well Dialyzed Patient during Renal Transplantation

Renal excretion and cellular uptake of potassium play key roles in the body's defense mechanism against hyperkalemia. Intra-operative hyperkalemia is an uncommon life-threatening complication during elective renal transplant surgery. We report herewith a non-insulin dependent diabetic kidney transplant recipient with prolonged pre-operative fasting, in whom, despite pre-operative hemodialysis, unforeseen high serum potassium level suddenly presented as wide-complex bradycardia during the surgery. The patient responded well to medical therapy of the hyperkalemia and the surgery was completed uneventfully. It is difficult to single out the exact cause of hyperkalemia in our patient. Prolonged pre-operative fasting for about nine hours, associated with insulinopenia and hyperglycemia, in the presence of beta-blockade and metabolic acidosis, have probably collectively resulted in efflux of potassium from intra-cellular stores. This potentially catastrophic complication should be remembered in diabetic patients undergoing any type of surgery.

Extrahepatic portal hypertension: a review of 70 cases

Among 70 children with extrahepatic portal hypertension, more than 350 episodes of bleeding occurred. Of the 32 children who were not operated upon, six (19%) died of bleeding. Twelve children in the nonoperated group are thriving and well, although six of them have rebled 1-2 times. The operated group of 38 children had a total of 43 procedures. Central splenorenal and cavomesenteric anastomosis prevented further bleeding in 10 of 12 cases in which follow-up is available. Operative mortality was 24%, the majority of which were in emergency procedures.