Non-fatal gastric mucormycosis in a renal transplant patient and review of the literature

Mucormycosis is historically associated with substantial morbidity and carries a very high mortality in renal transplant patients. The common sites of involvement include cerebral, pulmonary, gastrointestinal, or disseminated lesions. We report the successful outcome of gastric mucormycosis along with Strongyloides stercoralis infection in a renal transplant patient, who has survived for 5 years. We also review the literature.

Chronic hepatitis C virus infection in renal transplant: treatment and outcome

BACKGROUND

Chronic hepatitis C virus (HCV) infection is a common cause of liver disease in post-renal transplant period and causes poor patient and graft survival. We analyzed the effects of antiviral therapy using ribavirin monotherapy or ribavirin in combination with interferon (IFN)-alpha in our kidney transplant recipients with chronic hepatitis C.

METHODS

Total of 14 patients received antiviral therapy, all of whom had stable graft function, raised aminotransferases and positive HCV viremia at the start of treatment. Eight patients received ribavirin alone for a period of six months to two yr, in doses of 400-800 mg daily. Five patients received IFN-alpha therapy for a period of two months to 1.5 yr, in doses of 1.5 million units daily or three million units thrice weekly with ribavirin. One patient received pegylated IFN 50 microg once weekly in combination with ribavirin. The response was seen in terms of biochemical and virological improvement at the end of study period.

RESULTS

In patients treated with ribavirin alone (n = 8), mean alanine aminotransferase (ALT) levels before and after treatment were significantly different (198.4 +/- 147.6 and 104.8 +/- 66.5 IU/L respectively; p < 0.05). ALT levels normalized completely in three patients at the end of treatment, improved in three patients and deteriorated in two. Only in one of eight patients on ribavirin alone, HCV-RNA became negative after six months of treatment while in the rest (n = 7) HCV-RNA continued to be positive. In subjects on IFN plus ribavirin (n = 6), the mean ALT levels decreased significantly (from 280.2 +/- 114.9 IU/L at baseline to 71 +/- 49 IU/L at end of therapy; p < 0.05). Two patients had sustained remission (33.3%) on IFN plus ribavirin (persistently negative HCV-RNA), two patients relapsed after initial remission and in two patients treatment was stopped after two months because of graft dysfunction. Totally four patients developed graft dysfunction at some time during the course of IFN therapy (66.6%), but it was discontinued in only two (33.3%). All patients regained normal creatinine levels after discontinuation of IFN, although one patient developed chronic allograft nephropathy as shown by kidney biopsy. Four patients in IFN group developed leucopenia. Two patients developed severe anemia one of whom required blood transfusion and one developed severe flu-like syndrome requiring stoppage of therapy.

CONCLUSION

Ribavirin monotherapy in renal transplant recipients with chronic hepatitis C infection results in good biochemical response but is not associated with virological clearance. IFN in combination with ribavirin is effective in two-thirds of patients after a minimum therapy of six months, but it is poorly tolerated, results in graft dysfunction in significant number of patients, and relapse can occur after stopping treatment.

Secondary prevention of fragility fractures: are we following the guidelines? Closing the audit loop

INTRODUCTION

The aim of this study was to determine whether orthopaedic surgeons follow the British Orthopaedic Association (BOA) guidelines for secondary prevention of fragility fractures.

PATIENTS AND METHODS

A retrospective audit was conducted on patients with neck of femur fractures treated in our hospital between October and November 2003. A re-audit was conducted during the period August to October 2004.

RESULTS

There were 27 patients in the initial study period. Twenty-six patients (96%)had full blood count measured with LFT and bone-profile measured in 18 patients (66%). Only nine patients (30%)had treatment for osteoporosis (calcium and vitamin D). Only one patient was referred for DEXA scan. Steps were taken in the form of creating better awareness among the junior doctors and nurse practitioners of the BOA guidelines. In patients above 80 years of age, it was decided to use abbreviated mental score above 7 as a clinical criteria for DEXA referral. A hospital protocol based on BOA guidelines was made. A re-audit was conducted during the period August to October 2004. There were 37 patients. All had their full blood count and renal profile checked (100%). The bone-profile was measured in 28 (75.7%) and LFT in 34 (91.9%) patients. Twenty-four patients (65%) received treatment in the form of calcium + vitamin D (20) and bisphosphonate (4). DEXA-scan referral was not indicated in 14 patients as 4 were already on bisphosphonates and for 10 patients their abbreviated mental score was less than 7. Among the remaining 23 patients, 9 patients (40%) were referred for DEXA scan. This improvement is statistically significant (P = 0.03, chi square test).

DISCUSSION AND CONCLUSIONS

The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation.

Successful complete regression of isolated intramedullary spinal cord metastases from epithelial ovarian carcinoma with chemotherapy and radiotherapy

Advances in the management of ovarian cancer by use of aggressive surgery and effective platinum-based chemotherapy have prolonged survival; this may have resulted in an alteration of the metastatic pattern of the disease and spread to unusual sites (e.g, CNS) has become more common. Also, with the availability of more sensitive imaging techniques, these tumors are being diagnosed with increasing frequency. Intramedullary spinal cord metastasis is rare. We report one such case treated successfully with chemotherapy and radiotherapy with long-term survival.

Y-type urethral duplication: an unusual variant of a rare anomaly

Urethral duplications are rare anomalies. We present a 3-year-old continent boy passing urine since birth per anus while voiding from penis. Micturating cystourethrogram, retrograde urethrogram and cystoscopy revealed a Y connection between the posterior urethra and anal canal. The accessory channel was excised by a perineal approach. Histopathology revealed that the tract was lined by transitional epithelium, proving that it was indeed a case of urethral duplication; hence, we suggest that all urethroanal fistulas are not variants of anorectal malformations. Certain of these fistulas should be considered as variants of Y-type urethral duplication even if the orthotopic urethra is normal.

Churg-Strauss syndrome as an unusual cause of spontaneous atraumatic intra-pericardial thrombosis

Intra-pericardial thrombosis is usually due to haemorrhage into the pericardial space or after traumatic pericardiocentesis. An unusual case of spontaneous atraumatic intra-pericardial thrombosis due to Churg-Strauss syndrome, which responded well to immunosuppressive therapy, is presented.

The annual risk of tuberculous infection in the eastern zone of India

SETTING

Rural and urban areas of eight selected districts in the eastern zone of India.

OBJECTIVES

To estimate the annual risk of tuberculous infection (ARTI).

STUDY DESIGN

A community-based, cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in a sample of rural and urban areas. Stratified two-stage cluster sampling was adopted for selection of rural and urban clusters. A total of 40964 children in 515 clusters underwent tuberculin testing and reading with 1TU PPD RT23 with Tween 80; the maximum transverse diameter of induration was measured about 72 h after the test.

RESULTS

A bacille Calmette-Gúerin (BCG) scar was observed in 51.5% of the test-read children. The frequency distribution of tuberculin reaction size among 19332 children without BCG scar was found to be bimodal, with the mode of reactions attributable to infection with tubercle bacilli at 20 mm. The prevalence of infection was estimated as 6.9%. The ARTI computed from the estimated prevalence was 1.3%. Children residing in the urban areas were found to be at a significantly higher risk of infection than those residing in rural areas.

CONCLUSION

The high rate of ARTI in the eastern zone of India suggests a need for committed, sustained action in provision of quality tuberculosis control services.

Functional ventricularisation of the left atrium--severe mitral valve prolapse paradoxically resulting in minimal regurgitation

Mitral valve prolapse is a common condition often associated with mitral regurgitation. Intuitively, one would expect a positive correlation between the severity of mitral valve prolapse and the associated regurgitation. This assumption is overturned by an unusual case of functional ventricularisation of the left atrium due to severe mitral valve prolapse which paradoxically resulted in minimal regurgitation.

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: a single centre Indian experience

BACKGROUND

Fungal peritonitis (FP) is a serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We reviewed our FP cases to analyse the causative agents and possible risk factors in relation to FP and its outcome and mortality.

METHODS

Records of all FP cases were reviewed. FP was diagnosed based on effluent cell count and positive fungal culture in suitable media.

RESULTS

Between October 1993 and November 2001, 261 patients underwent CAPD. FP was detected in 28 patients, one episode in each patient (14.3% of the total peritonitis episodes). Candida species and dematiaceous fungi+/-Candida species were responsible for 89.3 and 10.7% of episodes, respectively. Patients with preceding bacterial peritonitis (BP) developed FP more frequently (25.6%) than de novo cases (2.9%) (P<0.0001) and lower proportion of them continued CAPD (8.6% vs. 60%; P=0.007). Mortality in patients having abdominal pain with and without fever, and catheter in situ was significantly higher than in those patients who did not have these risk factors (9/11 vs. 6/17, P=0.01; 13/17 vs. 2/11, P=0.003; 6/6, vs. 9/22, P=0.01, respectively).

CONCLUSIONS

Higher proportion of our patients had FP; preceding BP was a significant risk factor for development of FP and technique failure. Abdominal pain+/-fever in patients and catheter in situ were identified as risk factors associated with mortality.

Assessment of ocular and nasal irritation in asthmatics resulting from fragrance exposure

BACKGROUND

Many asthmatics report worsening of symptoms following exposure to odours and sensory irritants commonly found in household and cosmetic products. Despite this, little evidence exists to confirm the degree to which such subjective reports are correlated with localized, objective changes in the upper or lower airways following a fragranced product exposure.

OBJECTIVE

Subjective symptom reports were compared to objective measures in mild asthmatics, moderate asthmatics and non-asthmatics following exposure to one of two fragranced household aerosol mixtures and a clean air control condition to determine if asthmatics reported greater subjective symptoms of nasal congestion or exhibited objective measures of elevated ocular irritation and nasal congestion following exposure than did healthy controls.

METHODS

Measures of nasal mucosal swelling, using acoustic rhinometry, and photographic assessments of ocular hyperemia, using macro-photography, were taken before exposure, immediately after an initial 5-min exposure and again following a 30-min exposure to either of two, fragranced aerosol products and a clean air control. Self-reports of nasal patency at each time-point were also obtained.

RESULTS

Although moderate asthmatics tended to report more nasal congestion following fragranced product exposure than did non-asthmatics, no exposure-related changes in ocular redness or nasal mucosal swelling were observed among the three groups. Spirometry readings also failed to show evidence of any exposure-related changes in pulmonary function.

CONCLUSION

Despite claims that exposure to fragranced products may trigger ocular and respiratory symptoms among asthmatics, we found no evidence that 30 min of exposure to one of two fragranced aerosols elicited objective adverse effects in the ocular or nasal mucosa of mild and moderate asthmatics. While physiological mechanisms of fragrance impact may yet be responsible for some of the adverse reports among asthmatics following fragrance exposure, such reports may also reflect a non-physiological locus of symptom perception triggered by other sensory cues.

Subjective visual experience during phacoemulsification cataract surgery under sub-Tenon's block

In a prospective survey, 121 patients received sub-Tenon's block and were interviewed on the same day after their phacoemulsification cataract surgery regarding their visual experience in the operated eye during surgery. Majority of patients (81%) reported that they could see some light during surgery and various colours were seen by 56%. Movements of various descriptions were also reported by 40% of patients. The majority of patients (93%) found the visual experience acceptable but 4% thought it to be unpleasant and 3% found it frightening. Patients undergoing phacoemulsification surgery under sub-Tenon's block experience a variety of visual sensations and some patients may be frightened. All patients should receive appropriate preoperative warning.