Acute paraquat poisoning in an adolescent with compromised outcome: A case report

Paraquat, a highly toxic herbicide, accounts for a substantial number of poisoning-related fatalities, primarily prevalent in agricultural regions. The ingestion gives rise to severe complications affecting various organs, including the lungs, gastrointestinal tract, kidneys and liver. This report details the case of an 18-year-old male who had been using cannabis for a year and inadvertently ingested paraquat. He presented at the emergency room exhibiting symptoms of vomiting characterized by hematemesis and regurgitated food particles, along with heartburn, dysphagia and reduced urine output. Given the absence of a specific antidote, the prognosis for paraquat poisoning remains generally unfavourable. Diagnosis relies on circumstantial evidence and clinical manifestations, necessitating a focus on supportive care. Presently, no specific antidote for paraquat poisoning is available. Efforts should concentrate on preventive measures, efficient decontamination strategies and vigilant stabilization protocols in instances of exposure.

Bilateral thalamic stroke due to occlusion of the artery of Percheron: A case report and literature review

Bilateral thalamic infarction resulting from the occlusion of the artery of Percheron (AOP) is a rare cerebrovascular event with distinctive clinical presentations. This case report explores the intricate relationship between vascular anatomy, midbrain function, and clinical manifestations. A 48-year-old male farmer with a history of diabetes mellitus presented with sudden-onset visual disturbances, diplopia, bilateral eyelid drooping, and loss of consciousness. Extensive evaluations, including advanced imaging techniques, led to the diagnosis of bilateral upper midbrain infarction involving AOP. This case underscores the complexity of neurovascular interactions, highlighting the importance of precise diagnosis, and tailored management in addressing rare cerebrovascular conditions.

Unregulated medication use and complications: a case study of prolonged self-treated tuberculosis in Nepal

BACKGROUND

Tuberculosis (TB) is a global public health issue, particularly in resource-constrained countries like Nepal. This case report highlights the consequences of prolonged self-treatment and non-compliance with TB management protocols, emphasizing the need for increased awareness and intervention.

CASE PRESENTATION

A 50-year-old male from Nepal self-medicated with anti-tubercular drugs for 13 years after completing the recommended course of treatment. He experienced worsening symptoms, including respiratory distress and visual impairment. Upon evaluation, he was diagnosed with chronic cavitary pulmonary aspergillosis. The patient received comprehensive treatment, including antifungal therapy, steroids, antibiotics, and respiratory support, resulting in significant improvement.

CONCLUSIONS

This case highlights the dangers of self-treatment and non-compliance with TB management protocols. It emphasizes the importance of patient education, awareness programs, and regular follow-up to ensure treatment adherence and detect complications. The case also reveals gaps in the DOTS (Directly Observed Treatment, Short Course) program, including the need for improved surveillance, and a multidisciplinary approach. The ease of over-the-counter purchase of anti-tubercular drugs in Nepal contributed to the patient's prolonged self-medication, highlighting a concerning. The complications arising from prolonged self-medication underscore the need for increased awareness, intervention, and patient education in TB management. Improving patient education, raising awareness about the risks of self-medication, and integrating ophthalmologic evaluations into standard management are essential for better TB control in Nepal.

A rare case of Behcet's disease in Nepal: multisystem manifestations and diagnostic challenges

Behcet's disease (BD) is a chronic inflammatory disorder characterized by a relapsing and remitting course and multisystem involvement. The authors present a case report of a 20-year-old male who presented with bilateral knee joint pain, oral and genital ulcers, and papulopustular skin lesions. The patient's clinical history, physical examination, laboratory findings, and biopsy results were consistent with the diagnosis of BD. The patient tested positive for the HLA-B51 allele, confirming a genetic predisposition. The diagnosis was supported by a positive pathergy test and a skin biopsy showing vasculitis. The diagnostic criteria established by the international study group and the International Criteria for Behcet's Disease were fulfilled. Treatment consisted of colchicine, azathioprine, and topical corticosteroids. This case highlights the importance of recognizing the varied clinical presentations of BD and the need for a multidisciplinary approach to diagnosis and management. Early and accurate diagnosis is crucial to prevent severe complications and improve patient outcomes.

A case of acute encephalitis syndrome and cranial nerve palsy secondary to scrub typhus: A rare presentation from Western Nepal

Key Clinical Message

This case report highlights the importance of considering scrub typhus as a differential diagnosis for acute encephalitis with cranial nerve palsy in the region of the tsutsugamushi triangle.

Abstract

Scrub typhus is a zoonotic rickettsiosis caused by the bacterium Orientia tsutsugamushi. This disease is endemic to a region called the tsutsugamushi triangle that extends from Southeast Asia to the Pacific Ocean. We report a 17-year-old girl from western Nepal who presented with fever, headache, vomiting, and altered sensorium, as well as bilateral lateral rectus palsy, dysphagia, regurgitation of food, dysarthria, and left-sided upper motor neuron type facial palsy. Following laboratory and imaging tests, the patient was diagnosed with scrub typhus and was treated successfully with high-dose dexamethasone and doxycycline. This case highlights the importance of considering scrub typhus in the differential diagnosis of encephalitis with cranial nerve palsy, especially in the region of the tsutsugamushi triangle. It also emphasizes the need for timely diagnosis and treatment of scrub typhus to prevent the development of various complications and ensure earlier recovery of patients.

Sagittal Root Position of Maxillary Anterior Teeth in Nepalese Population Using Cone Beam Computed Tomography

Background There are no radiographic studies in Nepalese population for determination of sagittal root positioning in maxillary anterior teeth. The sagittal root positioning and root angulation plays a vital role for case selection in immediate implant placement. Objective To evaluate, classify and compare sagittal root position between different maxillary anterior teeth. Method A 2-year retrospective study was conducted on 100 patients (53 males and 47 females) who fulfilled the inclusion criteria using cone beam computed tomographic images. The relationship of root of tooth to its alveolar housing were recorded as Class I to IV. In addition, the root angulation relative to the alveolar process was also measured. Result The sagittal root position (SRP) calculated on six maxillary anterior teeth on average was found to be 87.83% for Class I, 6.67% for Class II, 0.67% for Class III and 5.17% for Class IV respectively. The mean root angulation was found to be higher with canines on both side whereas lateral incisors had lesser mean root angulation. Root angulation of maximum teeth were between 10-20 degrees where immediate implant placement is possible. Conclusion Within the limitations of this study, the sagittal root positioning and root angulation in Nepalese population showed a favorable result for immediate implant placement. Maximum teeth were found to be close to the alveolar process with the exception of few teeth.

Crown Lengthening Surgery for Enhancing Restorative Treatment in Esthetic Zone

For obtaining adequate retention for restoring cases like subgingival caries or extensive caries that shortens the tooth, short clinical crown, and fractures, it is usually necessary to disclose more tooth structure. Crown lengthening procedure is done to increase the clinical crown length for restorative or esthetic reasons without breaching the biologic width. These procedures are also utilized to improve the appearance and retention of restorations placed within the esthetic zone. We report a case of crown lengthening surgery with an internal bevel gingivectomy which was done in our department without compromising tooth support and esthetics.

Necrotizing Stomatitis in Varicella Zoster Infection

Necrotizing periodontal disease are acute periodontal conditions which can present with simple gingivitis to more complex life threatening condition where it can perforate the skin of cheek. They are found in patients with severe illness, stress and reduced immunity. The prevalence of this whole group of disease is usually very low and is stated frequently as the first manifestation in HIV infection. Herpes zoster, a common dermatological condition is a secondary infection due to re-activation of Varicella zoster virus in a person previously acquiring a chicken pox in his/her lifetime. There are limited scientific literatures citing the occurrence of necrotizing stomatitis in varicella zoster infection. Thus, here we present a detail about a case and management of 46 years old female who had a hospital stay of over 5 days for treatment of Herpes zoster infection of mandibular nerve presented with necrotizing stomatitis lesion within oral cavity.

The Study of Burden of Family Caregivers of Patients Living with Psychiatric Disorders in Remote Area of Nepal

Background Family caregivers of psychiatric disorders likely to face burden. There is a paucity of data regarding the caregiver burden in psychiatric disorders in context of Nepal. Objective To study the caregiver burden in families with psychiatric illness and to find association between socio-demographic variables and caregiver burden in families with psychiatric illness. Method This is an analytical cross-sectional study. The participants (n=96) were caregiver of patients visiting outpatient department of two government of Nepal primary health care centers namely, Panchkhal Primary Health Care Center (PHC) Kavre District and Barhabise Health Care Center Sindhupalchowk district. The sample size has been determined by using statistical formula. Family burden assessment schedule (FBIS) was used for the study. Result The majority of the caregivers were females 56.3%. Most of the caregivers were aged below 45 years 54.2%. The large number of participants were single or separated 74%. The mean score of family burden assessment schedule was 27 ± 9.8 (range 0 to 48) with positive rate of 59.4%.Among the objective burden domains disruption of family leisure 61.5% was the most frequently reported burden. The subjective burden was reported in 95%. There were significant differential demographic associations with different domains of caregivers' burden. Conclusion Caregivers of Psychiatric patients experience different kind of burden of care. Our findings highlight the support to the family members to reduce their burden.

Study of Infertile Couples Attending a Teaching Hospital in Eastern Nepal

INTRODUCTION

Infertility is a global health issue and a socially destabilizing condition for couples with several stigmas including medical, social, psychological burdens and a marital disharmony. The aim was to study the incidence of infertility in couples attending outdoor of Nobel Medical College and to know the contributing factors among the infertile couples.

METHODS

A prospective cross-sectional study was carried out in the outpatient department of a teaching hospital July 2015-June 2016, where the incidence of infertility and the contributing factors for the same were evaluated.

RESULTS

The incidence of infertility in this study was 5.45% and it was dominated by secondary infertility. The most important cause was male factor in 37.39%. Majority of male factor abnormality was due to exposure to heat as these male work abroad in Arabian Countries.

CONCLUSIONS

The study shows a dominance of secondary infertility and male factor being a major contributor. The most common semen abnormality was oligospermia.

Myomectomy Revisited: Experiences in a Teaching Hospital

INTRODUCTION

Uterine myomas are the most common benign tumors of the female reproductive tract with myomectomy being one of the major modalities of the treatment in our set up. The aim of this study was to share the experiences of open myomectomy from a Teaching Hospital.

METHODS

A observational study was conducted from a records of myomectomy cases in the department of Obstetrics and Gynaecology at Nobel Medical College teaching Hospital from June 2014- May 2016.

RESULTS

Total 38 cases of myomectomy were performed during the study period in the women most commong age group being 35-39 years, followed by 30-34. The most common presenting symptoms was abnormal uterine bleeding in 15 (39.47%) followed by mass per abdomen in 10 (26.31%). The most common location of the myoma was intramural followed by subserosal, submucus. Degeneration was also noted in majority of the cases. All the myomectomies were done with Inj Vasopressin injected paracervically except in one case where tourniquet was used. None of the patients had significant post-operative morbidity except fever in the first 24 hours.

CONCLUSIONS

Abdominal myomectomy is a safe and effective procedure for uterine myomas for infertile women in the past but it should be offered to those desiring for uterine preservation irrespective of age and reproductive status.

Neuroleptic malignant syndrome: case report

Neuroleptic Malignant Syndrome (NMS), a potentially fatal complication of neuroleptic therapy is described. It is found to be associated with a variety of medical and psychiatric conditions. Various risk factors and non specific investigations pathognomic to various medical conditions has been proposed. The mortality and morbidity associated with NMS can be decreased with early recognition, early discontinuation of the neuroleptics and aggressive treatment.

Evaluation of dialysis adequacy in patients under hemodialysis and effectiveness of dialysers reuses

Reuse of dialysers is being practiced since the start of hemodialysis (HD) service in Nepal, which is cost effective as well as safe. A retrospective study was done in Nepal Medical College and Teaching Hospital. We reviewed case records of the year 2008 and retrieved required data such as pre and post urea, post dialysis weight and ultrafiltration volume from 186 sessions of dialysis of 60 patients. Dialysis sessions were divided into nine groups according to the number of use of dialyser. Out of 60 patients, 40 were male. Mean age of the study population was 45.82 +/- 15.42 yrs (range 18-78). Dialysers were reprocessed manually up to 9 times. Adequacy of dialysis was assessed using single pool Kt/v (spKt/v) and urea reduction rate (URR). Mean pre urea, post urea and spKt/v were 160 +/- 51.2 mg/dL, 71.8 +/- 28.5 mg/dL and 0.95 +/- 0.28 respectively. Mean URR was 54.82 +/- 11.24%. Out of total 186 sessions, spKt/v was > or = 1.2 in only 31 sessions (17.0%). There was no significant difference in mean spKt/v between the groups (p=0.87). When compared between the individual groups e.g. 1st vs. 7th, 1st vs. 8th and 1st vs. 9th, there was no significant difference in spKt/v. Dialysis is inadequate in most of our patients undergoing HD twice a week. Reuse of dialyser is effective in urea clearance and the practice of reuse is cost effective and safe.

Vascular access for hemodialysis in Nepal Medical College and Teaching Hospital

Good vascular access is an essential component for hemodialysis (HD). Studies in patterns of vascular accesses used for HD are very few. Eighty two (male 55, female 27) patients attending HD unit of Nepal Medical College and Teaching Hospital (NMCTH) over a period of one year were enrolled for the study. Average age was 46.12 years. Seventy four patients (90.0%) were suffering from chronic kidney disease (CKD) 5 and 8 (10.0%) patients had acute renal failure. Initial vascular access used was temporary vascular access in 76 (93.0%) and arteriovenous (AV) fistula in 6 (7.0%) patients. As a first temporary vascular access femoral catheterization was used in 54 (66.0%) patients followed by subclavian and internal jugular vein catheterization in 18 (22.0%) and 4 (5.0%) respectively. Fever was observed in 9 (11.0%) patients with first temporary access. There was no complication in 65 (79.0%) cases. Other complications were poor flow, malposition, infection, thrombosis, aneurysm and self removal of catheter. Only 47 patients were analyzed for the second vascular access. Trends towards use of second vascular access was subclavian and internal jugular vein cannulation in 20 (42.5%) and 10 (21.3%) respectively, AV fistula in 13 (27.7%), and femoral catheterization in 4 (8.5%). Second vascular access was associated with fever in 7 (14.9%) and limb swelling in 1 (2.1%). Temporary vascular access was the most common access to initiate HD in CKD 5. Only 7.0% of the patient had AV fistula to start HD. Femoral vein catheterization was the most commonly used first temporary vascular access. Complications with the vascular accesses were negligible.

In-center hemodialysis for end stage kidney disease at Nepal Medical College and Teaching Hospital

End stage kidney disease (ESKD) is defined by glomerular filtration rate (GFR) less than 5 ml/min. These patients need renal replacement therapy (RRT). Hemodialysis is an established form of RRT. Studies on incenter hemodialysis are very few. Here we would like to present our experience on in-center hemodialysis in Nepal Medical College and Teaching Hospital. Study period was one year (1st Baisakh 2065 to 31st Chaitra 2065). Total 33 patients (23 male, 10 female) were enrolled in the study. Average age was 42.33 +/- 15 years. Hypertension (55.0%), diabetes mellitus (24.0%), chronic glomerulonephritis (15.0%), rapidly progressive glomerulonephritis (3.0%) and others (3.0%) were the causes of ESKD requiring dialysis. Hypotension, hypertension, muscle cramps, chest pain were the common complications observed during dialysis. Average haemoglobin level was 9.44 +/- 1.88 g%. Majority of patients were physically inactive. Blood transfusion was the main modality for correction of anaemia. Approximate cost for one session of hemodialysis was Rs. 2000 (U.S. $.25) and average monthly income of study population was Rs.16312.5 (U.S. $.204) U.S. $1 = NRs.80, (4th May 2009).