'It's just a mucocele': a case report of a massive appendiceal mucocele presenting as a left upper quadrant mass

Tumours of the appendix are very rare tumours that can and often present with a mucocele. This is a case report highlighting the associated pathology of appendix tumours and the management of a large mucocele. Specifically, how a right hemicolectomy is very rarely needed in these cases regardless of size and local anatomical relationships and some important considerations for the practicing surgeon in the non-tertiary centre that encounters a case like this.

White matter predictors of PTSD: Testing different machine learning models in a sample of Black American women

BACKGROUND

Machine learning neuroimaging studies of posttraumatic stress disorder (PTSD) show promise for identifying neurobiological signatures of PTSD. However, studies to date, have largely evaluated a single machine learning approach, and few studies have examined white matter microstructure as a predictor of PTSD. Further, individuals from minoritized racial groups, specifically, Black individuals, who experience disproportionate trauma frequency, and have relatively higher rates of PTSD, have been underrepresented in these studies. We used four different machine learning models to test white matter microstructure classifiers of PTSD in a sample of trauma-exposed Black American women with and without PTSD.

METHOD

Participants included 45 Black women with PTSD and 89 trauma-exposed controls recruited from an ongoing trauma study. Current PTSD presence was estimated using the Clinician-Administered PTSD Scale. Average fractional anisotropy of 53 white matter tracts served as input features. Additional exploratory analysis incorporated estimates of interpersonal and structural racism exposure. Classification models included linear support vector machine, radial basis function support vector machine, multilayer perceptron, and random forest.

RESULTS

Performance varied notably between models. With white matter features along, linear support vector machine demonstrated the best model fit and reached an average AUC = 0.643. Inclusion of estimates of exposure to racism increased linear support vector machine performance (AUC = 0.808).

CONCLUSIONS

White matter microstructure had limited ability to predict PTSD presence in this sample. These results may indicate that the relationship between white matter microstructure and PTSD may be nuanced across race and gender spectrums.

Robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy: technical considerations and case vignette

When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less important for patient outcomes. We performed a minimally invasive approach to surgery for LARC invading the posterior vagina and sacrum. The patient was a 75-year-old lady who presented with a locally advanced rectal tumour staged T4N2 with invasion into the posterior wall of the vagina and coccyx/distal sacrum. We introduce a robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy using a purely perineal approach with no robotic adjuncts or intracorporal techniques. Final histology showed moderately differentiated adenocarcinoma invading the vagina and sacrum, ypT4b N0 TRG2 R0 and the patient entered surgical follow-up with no immediate intra- or postoperative complications. A literature review shows the need for more minimally invasive techniques when relating to major pelvic surgery and the benefits of a purely perineal approach include less expensive resource use, fewer training requirements and the ability to utilise this technique in centres that are not robotically equipped.

Tranexamic acid, as an adjunct to oxytocin prophylaxis, in the prevention of postpartum haemorrhage in women undergoing elective caesarean section: A single-centre double-blind randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of tranexamic acid (TXA) in reducing blood loss during elective caesarean sections in women with and without risk factors for postpartum haemorrhage (PPH).

DESIGN

A double-blind, randomised placebo-controlled trial.

SETTING

An academic tertiary referral centre in Singapore.

POPULATION

Multiethnic women aged 21 years or older undergoing elective caesarean section.

METHODS

Randomisation to intravenous TXA or normal saline (placebo) 10 minutes before skin incision.

MAIN OUTCOME MEASURES

Calculated estimated blood loss (cEBL), derived from blood volume and haematocrit levels.

RESULTS

Between June 2020 and October 2021, 200 women were randomised to the placebo or TXA groups. Women who received prophylactic TXA had a significantly lower mean cEBL compared with those receiving placebo (adjusted mean difference -126.4 mL, 95% CI -243.7 to -9.1, p = 0.035). The effect was greatest in those at high risk for PPH, with a reduction in cEBL (mean difference -279.6 mL, 95% CI -454.8 to -104.3, p = 0.002) and a lower risk of cEBL ≥500 mL (risk ratio [RR] 0.54, 95% CI 0.36-0.83, p = 0.007) and cEBL ≥1000 mL (RR 0.44, 95% CI 0.20-0.98, p = 0.016). Subgroup analysis showed benefit for women with preoperative haemoglobin <10.5 g/dL (mean difference -281.9 mL, 95% CI -515.0 to -48.8, p = 0.019). There was no significant difference in need for additional medical or surgical interventions. There were no maternal or neonatal adverse outcomes.

CONCLUSION

Prophylactic TXA should be considered in women with risk factors for PPH, and those most likely to benefit are those with preoperative haemoglobin <10.5 g/dL.

Artificial intelligence in dermatology: the "unsupervised" learning

The potential areas of application of artificial intelligence in dermatology are ever-increasing. With the wide availability of smartphones equipped with high-resolution cameras and impressive processing powers, harnessing these capabilities using machine learning (ML) could open new prospects in the management of dermatological disorders. Du-Harpur et al. have done a commendable job reviewing the utility of artificial intelligence in dermatology in an easily understandable manner by most dermatologists1 .

Trichoscopy of primary cicatricial alopecias: an updated review

Trichoscopy is an emerging technique for the evaluation of various hair and scalp disorders including primary cicatricial alopecias (PCAs). Early diagnosis of PCAs can lead to effective management and trichoscopy could be a useful aid during this process. Multiple studies have reported the trichoscopic features of PCAs, however, a focused review evaluating these disorders with their trichoscopic features is lacking. With the objective of evaluating the trichoscopic findings reported in the literature for various PCAs, we conducted a systematic literature search in PubMed and Embase. The search yielded 310 studies in a total of which 54 studies were included in our review. Majority of these studies originated from the Caucasian or Asian population. Through this review, we provide an overview of the frequent and specific trichoscopic findings in different PCAs with their clinical significance where applicable based on the current knowledge and identify the areas for future research.

Tricuspid valve leaflet strains in the beating ovine heart

The tricuspid leaflets coapt during systole to facilitate proper valve function and, thus, ensure efficient transport of deoxygenated blood to the lungs. Between their open state and closed state, the leaflets undergo large deformations. Quantification of these deformations is important for our basic scientific understanding of tricuspid valve function and for diagnostic or prognostic purposes. To date, tricuspid valve leaflet strains have never been directly quantified in vivo. To fill this gap in our knowledge, we implanted four sonomicrometry crystals per tricuspid leaflet and six crystals along the tricuspid annulus in a total of five sheep. In the beating ovine hearts, we recorded crystal coordinates alongside hemodynamic data. Once recorded, we used a finite strain kinematic framework to compute the temporal evolutions of area strain, radial strain, and circumferential strain for each leaflet. We found that leaflet strains were larger in the anterior leaflet than the posterior and septal leaflets. Additionally, we found that radial strains were larger than circumferential strains. Area strains were as large as 97% in the anterior leaflet, 31% in the posterior leaflet, and 31% in the septal leaflet. These data suggest that tricuspid valve leaflet strains are significantly larger than those in the mitral valve. Should our findings be confirmed they could suggest either that the mechanobiological equilibrium of tricuspid valve resident cells is different than that of mitral valve resident cells or that the mechanotransductive apparatus between the two varies. Either phenomenon may have important implications for the development of tricuspid valve-specific surgical techniques and medical devices.

Clinicohistopathological correlation of leprosy

BACKGROUND: Leprosy is a chronic infectious granulomatous disease caused by Mycobacterium leprae. It is a spectral disease which is classified into five groups according to Ridley and Jopling based on clinical, histological, microbiological and immunological criteria. Adequate clinical information combined with bacilloscopy and histopathology is helpful not only in classification of different types of leprosy but also useful for management of the cases.METHOD: 50 cases of leprosy were examined and clinical data was recorded. Slit skin smears were stained with Ziehl Neelsen stain. Skin biopsy was stained with Hematoxylin-Eosin stain and Fite Farraco stain was performed to demonstrate acid fast bacilli. All patients were classified according to Ridley & Jopling classification. Clinico-histopathological correlation was done. Statistical analysis was done using SPSS (Statistical Package for the Social Sciences) 16.0.RESULTS: Most common histological type of leprosy was tuberculoid leprosy seen in 19(38%) cases followed by indeterminate leprosy. Overall clinico-histopathological correlation was seen in 39.58%. The correlation was highest in indeterminate and histoid leprosy (100%) followed by lepromatous leprosy (66.66 %%) and tuberculoid leprosy (50%). Slit skin smear showed bacilli in 12 out of 48 cases (25%) while biopsy showed bacilli in 16 out of 48 cases (33.3%).CONCLUSION: In the present study, clinical diagnosis did not correlate with histopathological diagnosis significantly (p value=0.04159). The study emphasizes the role of histopathological and bacilloscopic examination to aid the clinical diagnosis for accurate typing of leprosy cases then better management of the patient.

Spectrum of giant cells and its significance on FNAC in breast lesions

Fine needle aspiration of breast is being performed from last several years. It is not uncommon to find giant cell on FNAC of breast smears .Giant cells arises from monocyte / macrophage lineage which are capable of fusion to form multinucleated giant cell. The common giant cell seen in breast on fna smears are foreign body , Langhan’s type , stromal giant cells , tumor giant cells and osteoclastic giant cell . It arises in benign as well as malignant lesions of the breast. Hence, their recognition and correct interpretation can be valuable to cyto pathologist who identifies the variation in diagnosis of pathology and to the clinician for the treatment modalities of different breast pathologies.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Clinicohistological Profile of Cutaneous Tuberculosis in Central Nepal

BACKGROUND

There are few studies on cutaneous tuberculosis in Nepal.

OBJECTIVE

To analyse the epidemiological, clinical and histological patterns of cutaneous TB over the past 5 years.

METHOD

Patients with cutaneous tuberculosis diagnosed from January 2010 to December 2014 at College of Medical Sciences, Chitwan, Nepal were included in the study. Chest radiography, routine investigations and screening for HIV was performed in all cases.

RESULT

A total of 47 clinical cases of cutaneous tuberculosis were diagnosed. The most commonly affected age group was 41-50 years. Male to female ratio was 1.5:1. Duration of cutaneous tuberculosis ranged from 1 month to 33 years. Lupus vulgaris was the most common clinical type (64%), followed by tuberculosis verrucosa cutis (19%). Two cases (4%) were diagnosed as papulonecrotic tuberculid. Overall, the most common site of involvement was extremities (55%) followed by head and neck, trunk, and perianal region. Histopathologic features of epitheloid cell granuloma with Langhans type giant cells were seen in 89% of cases, and in remaining 11% cases, chronic inflammatory dermatitis and nonspecific chronic dermatitis were observed.

CONCLUSION

M Tuberculosis is endemic in Nepal and the incidence of cutaneous tuberculosis at our centre was 0.1%. Lupus vulgaris was the most common type followed by tuberculosis verrucosa cutis in our study. Cutaneous tuberculosis can be accompanied by tuberculosis in internal organs and hence should be looked for. Clinicopathologic correlation is necessary to make a proper diagnosis.

Intravenous Iron Sucrose Therapy in Iron Deficiency Anemia in Antenatal and Postnatal Patients

INTRODUCTION

Dermatophytosis is a common superficial fungal infection of the skin, hair and nails caused by Trichophyton, Microsporum and Epidermophyton dermatophytic species. Identification of causative dermatophytic species tend to vary with time and place and antifungal sensitivity is of epidemiological concern as well as significant for the treatment with precision at the current scenario of increasing antifungal resistance. The objectives was to study clinicomycological profile and antifungal sensitivity pattern of commonly used azoles in dermatophytosis.

METHODS

The prospective analysis of 145 clinically suspected cases of dermatophytosis was conducted from January 2014 to January 2015 at Department of Dermatology of COMS, Bharatpur, Chitwan, Nepal. Cases were evaluated and data recorded as per proforma. Samples were collected for microscopy and culture from skin, hair and nail. Antifungal sensitivity pattern was evaluated by standard disk diffusion technique.

RESULTS

Maximum numbers of cases with dermatophytosis were observed between June to September with male to female ratio of 1.4:1. The youngest patient was 3 years and the oldest was 76 years. Tinea corporis (25.5%) was the dominant clnical type observed. Overall direct microscopy (KOH) positivity and culture positivity was 64.8% and 57.2% respectively. Predominant species of dermatophyte isolated was T. mentagrophyte (23.4%). Out of five antifungals used in our study, fluconazole and ketoconazole were found 100% resistant.

CONCLUSIONS

This study highlighted the increasing resistance of the antifungals, which is responsible for the treatment failure in dermatophye infections.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Outcomes of children with abdominal compartment syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations.

OBJECTIVE

To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS.

SETTING

25 bed tertiary pediatric intensive care unit.

PATIENTS

PATIENTS less than 50 kg on mechanical ventilation and a urethral catheter.

MEASUREMENTS

Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored.

MAIN RESULTS

14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondary ACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17 - 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of ≥17 were predictive of developing ACS.

CONCLUSIONS

ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Single donor-derived strongyloidiasis in three solid organ transplant recipients: case series and review of the literature

Donor-derived Strongyloides stercoralis infections in transplant recipients are a rare but recognized complication. In this case series, we report donor-derived allograft transmission of Strongyloides in three solid organ transplant recipients. Following detection of infection in heart and kidney-pancreas recipients at two different transplant centers, a third recipient from the same donor was identified and diagnosed. S. stercoralis larvae were detected in duodenal aspirates, bronchial washings, cerebrospinal fluid, urine and stool specimens. Treatment with ivermectin and albendazole was successful in two of the three patients identified. The Centers for Disease Control and Prevention was contacted and performed an epidemiologic investigation. Donor serology was strongly positive for S. stercoralis antibodies on retrospective testing while all pretransplant recipient serum was negative. There should be a high index of suspicion for parasitic infection in transplant recipients and donors from endemic regions of the world. This case series underscores the need for expanded transplant screening protocols for Strongyloides. Positive serologic or stool tests should prompt early treatment or prophylaxis in donors and recipients as well as timely notification of organ procurement organizations and transplant centers.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.

Contact dermatitis – Pathomechanism and understanding of disease in clinical setting

According to the pathophysiological mechanisms involved, two major types of contact dermatitis recognized irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). The diagnosis of either ICD or ACD is mainly depending on comprehensive clinical data (history and physical examination) as well as by performing appropriate diagnostic patch testing. Two forms of contact dermatitis may differ in early phase of development but development of clinical dermatitis have similar mechanism confusing the clinician and differentiating between ICD and ACD is often difficult in the clinical setting. This review will allow practicing physician to adopt rational clinical approach and the implementation of scientific information for therapeutic as well as preventive strategies. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 70-77 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6816

Erthroplasia of queryat- A case report

Erthroplassia of Queryat (EQ) is a rare squamous cell carcinoma in situ of the penis. It usually occurs on the glans penis and appears as a well-marginated erythematous velvety patch or plaque. Here, we present a case of Erthroplasia of Queryat (EQ). Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 67-69 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6815

Multiple familial trichoepithelioma: A case report

Trichoepithelioma are benign epidermal appendageal tumour with follicular differentiation. Tumor has been categorized into solitary, multiple and desmoplastic types. The multiple familial trichoepithelioma is autosomal dominant inheritance and rarely seen. Journal of College of Medical Sciences-Nepal,2011,Vol-6,No-4, 64-68 DOI: http://dx.doi.org/10.3126/jcmsn.v6i4.6731

An intravenous biological therapy for psoriasis: Infliximab

Psoriasis is a common, chronic inflammatory skin disease which typically follows a relapsing and remitting course and is associated with joint disease. The significant reduction in quality of life and the psychosocial disability suffered by patients underline the need for prompt, effective treatment and long-term disease control. Patients with moderate to severe disease often require systemic treatment with effective & new modalities such as biological-Infliximab. Review will highlight fundamental aspects of infliximab and its use in Psoriasis as well as provide specific comments regarding this monoclonal antibody and its position in of psoriasis in the future treatment. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5977 JCMSN 2011; 7(1): 69-72

"Epizoonosis of dermatophytosis": a clinico- mycological study of dermatophytic infections in central Nepal

BACKGROUND

Identification of dermatophytic species in clinical settings are important not only for epidemiological but also for the treatment.

OBJECTIVES

Present study was carried out to find out the clinical variants of Dermatophytosis and species of fungus responsible for the disease.

METHODS

The prospective observational analysis of 200 clinically suspected cases of dermatophytic infection attending Dermatology department of College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal. Skin scraping, hair and nail samples were collected and processed according to standard protocol.

RESULTS

Maximum number of patients enrolled in study were reported for treatment 5-8 weeks after the onset of disease. Overall male predominance was observed and ages between 26-30 years. Tinea corporis was the most common clinical type of tinea with female dominance in our study. 10 % of cases were having extensive Tinea. 71.5% of samples were positive on direct microscopy and 62 % positive on culture. Samples from T capitis were highest positive by direct microscopy (80%) and over all dominant species of fungus isolated in our study was Trichophyton verrucosum (30.6%).

CONCLUSIONS

The study highlighted Tinea corporis as the most common clinical type with female predominance. Overall predominant causative fungal species isolated was Trichophyton verrucosum.

Candidal infections of ventriculoperitoneal shunts

Although ventriculoperitoneal (VP) shunt infection is a common complication of shunt procedures, fungal infection is considered to be rare. In the present study, we performed retrospective analysis of six cases in which candida infection occurred. In all these six cases, VP shunt was performed in children for hydrocephalus and the onset of symptoms varied between seven days to one month after the surgical procedure was performed. The commonest clinical signs and symptoms were fever (100%), vomiting (100%), and altered sensorium (50%). The commonest isolate was Candida albicans (66.66%) followed by Candida parapsilosis and Candida glabrata in one case each. All the patients were successfully treated with Amphotericin B and there was no mortality recorded.

Vibrio vulnificus Diarrhea in a Child with Respiratory Infection

Vibrio vulnificus is a rare cause of disease and it is often unrecognized and underreported. It is a lactose-fermenting, halophilic vibrio causing severe disease in immunocompromised patients, but causing a mild type of gastroenteritis in healthy people, usually associated with consumption of seafood. We report here a case of diarrhea due to V. vulnificus in a male child who was admitted for fever, loose motions and productive cough. There was no history of consumption of any seafood; so, the source of infection could not be traced. As V. vulnificus is a rare entity, clinicians should have a high index of suspicion for the bacteria, when patients present with gastrointestinal illness, fever or shock, with or without ingestion of raw seafood. Pediatricians should also be alert as the bacterium causes a potentially fatal disease in children.

Renal abscess due to Escherichia coli in a child

Among the various intraabdominal abscesses, renal abscess is a rare entity, especially in children and accounts for a number of cases of "missed diagnoses." Drainage of pus and appropriate antibiotic therapy is the gold standard for treatment. Here we report a case of left renal abscess in a 6-year-old female child secondary to renal calculus. The patient presented with abdominal pain and mild fever for three months and the diagnosis was made by X-ray in the kidney, ureter and bladder (KUB) region, intravenous pyelography and ultrasonography of the abdomen. Escherichia coli was isolated from pus obtained by percutaneous drainage under sonographic guidance. The patient responded to intra-venous ceftriaxone, amikacin, and percutaneous drainage.

Diarrheagenic E. coli in hospitalized patients: special reference to Shiga-like toxin producing Escherichia coli

PURPOSE

This study was conducted to study the prevalence of diarrheagenic Escherichia coli (DEC) in dysentery cases with special reference to Shiga-like toxin producing Escherichia coli (STEC).

METHODS

During a two-year period, 1066 stool samples were collected from hospitalized patients with diarrhea and dysentery. After taking detailed clinical history and observing the gross and microscopic findings of the stool samples, they were cultured on MacConkey and Sorbitol MacConkey agars and E.coli isolates were identified by standard biochemical tests.

RESULTS

Of the 100 E.coli strains isolated in pure culture and sent for sero typing to Central Research Institute (CRI), Kasauli, 43% were found to be DEC, giving an isolation rate of 4.03%. Results of sero typing showed 37.21% STEC which were more common in children. Abdominal pain and stool with mucus flakes were statistically significant parameters (p less than 0.01) in patients with dysentery due to E.coli strains. Though E.coli O157 was not encountered, it was seen that 25% of STEC did not ferment sorbitol. The DEC strains showed maximum in vitro sensitivity to amikacin (83.72%) and all strains were resistant to nalidixic acid. Antibiotics along with ORS and intravenous fluids had to be given in 68.42% patients. As complications, about 16.67% of children developed hemolytic uremic syndrome (HUS),and 10.53% of patients developed acute renal failure. No mortality was reported.

CONCLUSION

Though Enterohemorrhagic E.coli (EHEC) O157:H7 was not encountered in this study, STEC caused by E.coli non O157 was reported. STEC is also known to cause hemorrhagic colitis (HC) and HUS. In this study HUS was reported in 16.67% children. Therefore, proper isolation and identification of STEC is essential in a tertiary care centre, to initiate prompt management and reduce morbidity and mortality in children.