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Patients with primary sclerosing cholangitis (PSC) are at risk of hepatobiliary and gastrointestinal cancers. Increased risk of cancer is a result of the chronic, progressive fibro-inflammatory state which ultimately results in the destruction of biliary ducts. PSC is often associated with inflammatory bowel disease (IBD). Patients with PSC are at significant risk of cholangiocarcinoma (CCA), gall bladder malignancy and those with IBD are at increased risk of colorectal cancer. It is important to implement cancer surveillance protocols in these patients. The aim of these protocols is the prevention or early detection of cancerous or pre-cancerous lesions. Given that PSC is rare, large prospective studies evaluating the risk of malignancy in these patients are not available. A great deal of uncertainty exists regarding how to best implement cancer surveillance in these patients. About 50% of deaths in PSC patients are due to malignancy and many patients eventually progress to end-stage liver disease and succumb to hepatic failure. In this review, we cover cancer surveillance strategies in PSC patients based on existing literature and expert opinions.

Background: CT angiography (CTA) and interventional radiology angiogram (IRA) are used in work-up of acute lower gastrointestinal bleed (LGIB). Method: Retrospective study of patients with active LGIB who underwent CTA. Divided into CTA(+) and CTA(-) groups. CTA(+) was divided into IRA(+) or IRA(-). Results: 24.1% (49/203) had CTA(+) and 75.9% (154/203) had CTA(-). No statistical significant difference was noted for hemodynamic parameters, anti-platelets and anti-coagulants, thrombocytopenia, elevated INR or blood transfusion across CTA(+) and CTA(-) groups. Median decision to test (DTT) time for CTA(+) was 98 compared to 124.5 min for CTA(-)(p= 0.039). Univariate analysis revealed DTT time as the only factor with statistically significant effect on CTA outcome. LR (p< 0.001) and Phi coefficient (p< 0.001) suggested significant difference in distribution and association between number of positive risk factors and CTA(+) respectively. In CTA(+), 81.6% (40/49) had a follow-up IRA with 32.5% (13/40) being IRA(+) while 67.5% (27/40) were IRA(-). Overall, 6.4% (13/203) patients had positive IRA. Majority of CTA were ordered by ER- 39.9% (81/203) and IM- 42.9% (87/203). For emergency department(ER)- 23.5% had CTA(+) and 3.7% had IRA(+) compared to Internal Medicine(IM) category- 25.3% had CTA(+)(p=0.78) and 5.7% had IRA(+)(p=0.53). 57.9% patients in CTA(+) had a follow-up IRA in ER category in contrast to 95.5% in IM (p=0.0038). Conclusion: One in sixteen patient benefits from CTA. IM did better than ER in selecting patients for CTA. Number of positive risk factors correlates with probability of CTA(+). Decreasing DTT time may be the key to improve diagnostic yield.

Background/Aims Esophageal stricture is usually managed with outpatient endoscopic dilation. However, patients with food impaction or failure to thrive undergo inpatient dilation. Esophageal perforation is the most feared complication, and its risk in inpatient setting is unknown. Methods We used National Inpatient Sample (NIS) database for 2007–2013. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes were used to identify patients with esophageal strictures. Logistic regression was used to assess association between hospital/patient characteristics and utilization of esophageal dilation. Results There were 591,187 hospitalizations involving esophageal stricture; 4.2% were malignant. Endoscopic dilation was performed in 28.7% cases. Dilation was more frequently utilized (odds ratio [OR], 1.36; p

Methotrexate (MTX) is considered an anchor drug in the treatment of rheumatoid arthritis. It is also the first-line therapy in a multitude of rheumatologic conditions. Low-dose oral MTX is the preliminary modality of treatment for rheumatoid arthritis due to its affordability, favorable outcomes, and limited risks. However, patients refractory to low-dose MTX therapy may require larger doses of oral MTX. Several studies in the past have demonstrated variability in bioavailability of oral MTX at high doses. This warrants a subsequent switch to parenteral MTX. Widely used among the parenteral preparations of MTX is subcutaneous (SC) MTX. SC MTX provides dependable efficacy, predictable bioavailability, sustained clinical outcomes, and minimal GI adverse effects. It is useful either singularly or in combination therapy regimens. Although SC MTX and intramuscular MTX have similar pharmacokinetics, SC MTX may be preferred by most patients. Development of prefilled syringes and auto-injectors have enabled self-administration of the medication providing the patients with a sense of independence and improved general well-being. Hence, SC MTX can prove to be more efficacious in patients refractory to oral MTX therapy or in patients experiencing severe gastrointestinal adverse effects.

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician’s awareness of NSM and its features to help tailor management according to the patient’s clinical profile.

IgG4-related disease (IgG4-RD) encompasses a spectrum of complex fibro-inflammatory disorders which are often under diagnosed due to unfamiliarity by clinicians. A challenging multitude of clinical manifestations makes the diagnosis cumbersome. The primary clinical feature in IgG4-RD entails a tumor-like presentation coupled with tissue-destructive lesions. Histopathological findings include lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis. These findings, in combination with elevated serum immunoglobulin G4 levels, are diagnostic in the setting of single- or multi-organ involvement. A closer understanding of the role of T cells and B cells in the increased production of IgG4 has led to a notion that IgG4 can act as a pathogen, anti-inflammatory agent, or rheumatoid factor. Glucocorticoids are the primary treatment modality; however, relapse is common with prolonged therapy. Alternatively, immunomodulatory agents are being increasingly used as therapy. The aim of this article is to raise awareness of IgG4-RD and review the diagnostic algorithm, as IgG4-RD often mimics a wide array of clinical conditions. In addition, we summarize the pathogenesis and current treatment guidelines of IgG4-RD for clinicians. Awareness and accurate diagnosis are crucial in preventing progression to chronic diseases, thereby diminishing disease-related morbidity and mortality.

Background. Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. Methods. This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. Results. Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p<0.05), lower mean peak troponin levels (12 versus 49, p<0.05), and lower mean length of stay (12 versus 25 days, p<0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. Conclusion. Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

Background: Rickettsial diseases are reemerging in many parts of our country. Scrub typhus is a rickettsial disease caused by Orientia tsutsugamushi. It is difficult to diagnose Scrub typhus because of nonspecific clinical presentation and lack of availability of specific tests (ELISA) in all centres. Aim: Our aim was to study the clinical features, lab parameters and outcome of patients diagnosed with Scrub typhus. Materials and Methods: A retrospective hospital based study was done in Mangalore (Karnataka) to identify cases of scrub typhus. Patients who had an acute febrile illness and IgM antibodies against O. tsutsugamushi were included in our study. Results: 10 cases of Scrub typhus were identified. Among them 7(70%) patients were females and 3(30%) were males. Major symptoms on admission were fever10(100%), dyspnea or cough-2(20%), rashes1(10%), altered sensorium1(10%). The major signs were fever10(100%), eschar 2(20%), and signs of meningial irritation in 1(10%). Lab parameters showed leukocytosis in 4(40%), thrombocytopenia in 3(30%), raised liver enzymes in 3(30%) and renal failure in 3(30%). Chest X-ray showed consolidation in 2(20%) patients. There was no mortality in our study. Conclusion: Scrub typhus can present with varying clinical manifestations and eschar can be absent in majority of cases as shown in our study. Therefore diagnosis should be based on a high index of suspicion and empirical treatment with doxycycline must be started whenever there is a strong suspicion of Scrub typhus. Asian Journal of Medical Science, Volume-5(3) 2014: 108-111 http://dx.doi.org/10.3126/ajms.v5i3.9213

Specific autoimmune and inflammatory rheumatic diseases have been associated with an increased risk of malignant lymphomas. Conditions such as rheumatoid arthritis (RA), primary Sjögren’s syndrome (pSS), systemic lupus erythematosus (SLE), dermatomyositis, and celiac disease have been consistently linked to malignant lymphomas. Isolated cases of lymphomas associated with spondyloarthropathies and autoinflammatory diseases have also been reported. Direct association between autoimmunity and lymphomagenesis has been reinforced by large epidemiological studies. It is still uncertain whether disease specific determinants or phenotypic or treatment related characteristics increase likelihood of lymphomagenesis in these patients. For example, recent literature has indicated a positive correlation between severity of inflammation and risk of lymphomas among RA and Sjögren’s syndrome patients. It is also debated whether specific lymphoma variants are more commonly seen in accordance with certain chronic autoimmune arthritis. Previous studies have revealed a higher incidence of diffuse large B-cell lymphomas in RA and SLE patients, whereas pSS has been linked with increased risk of mucosa-associated lymphoid tissue lymphoma. This review summarizes recent literature evaluating risk of lymphomas in arthritis patients and disease specific risk determinants. We also elaborate on the association of autoimmune arthritis with specific lymphoma variants along with genetic, environmental, and therapeutic risk factors.

Multiple liver abscess is a life threatening condition with high mortality. We present a case of a 59 yr old gentleman who developed multiple hepatic abscesses due to an appendicular mass. He was treated with parenteral antibiotics and ultrasound guided needle aspiration of the largest abscess was done. He recovered promptly with complete resolution of the liver abscesses. The main aim of this case report is to highlight the fact that multiple pyogenic liver abscesses can be managed with antibiotic treatment and needle aspiration. DOI: http://dx.doi.org/10.3126/ajms.v5i2.8725 Asian Journal of Medical Science, Volume-5(2) 2014: 137-139

Cryopyrin-associated periodic syndromes (CAPS) is a rare group of autoinflammatory disorders that includes familial cold autoinflammatory syndrome or FCAS, Muckle-wells syndrome or MWS, and neonatal-onset multisystem inflammatory disease or NOMID. CAPS is caused by a mutation in the NOD-like receptor family, pyrin domain containing 3 (NLRP3) gene. This ultimately leads to increased production of interleukin (IL)-1β. IL-1β is a biologically active member of the IL-1 family. It is not only a pro-inflammatory cytokine responsible for features such as fever, rash, and arthritis, but is also a major mediator in the central pathways of fatigue. Fatigue is a major component of CAPS and is associated with severely compromised quality of life. In clinical studies, fatigue was measured using functional assessment of chronic illness therapy-fatigue or FACIT-F and short form-36 or SF-36, physical component score instruments. These questionnaires can also be used to monitor improvement of fatigue following initiation of therapy. IL-1 inhibitors block the IL-1 signaling cascade, thereby preventing systemic inflammation in CAPS. The decrease in systemic inflammation is accompanied by improvement in fatigue.

Paradoxical tuberculosis – immune reconstitution syndrome (pTB-IRIS) is a well-recognized cause of clinical deterioration in HIV tuberculosis (HIV-TB) co-infected individuals following initiation of antiretroviral therapy (ART). Here, we present a rare presentation of pTB-IRIS which manifested as a prostatic abscess in a case of HIV positive patient. To the best of our knowledge this is the first reported case of pTB-IRIS reported in literature which manifested as a prostatic abscess. Paradoxical TB-IRIS manifesting as prostatic abscess is extremely rare and a high index of clinical suspicion is needed to diagnose and appropriately treat it. DOI: http://dx.doi.org/10.3126/ajms.v5i4.9498 Asian Journal of Medical Sciences 2014 Vol.5(4); 111-112