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Background: Prediction of outcome of critically ill patients helps in early aggressive therapy, optimum resource allocation and counselling of the family. This study was conceived to assess the predictive value of microalbuminuria, which is an underutilised biomarker. Methods: This was a longitudinal observational study conducted between March 2018 and June 2019 to assess microalbuminuria in patients with and without sepsis and to evaluate whether the degree of microalbuminuria could predict mortality in sepsis, and its association with to the acute physiology and chronic health evaluation II (APACHE II) score and the sequential organ failure assessment (SOFA) scores. Results: Among the 105 patients studied, 56 (53.3%) were male. This included patients with sepsis (n = 51) and without-sepsis (n = 54). The mean APACHE II score in sepsis group was 11.5 ± 3.5, in non-sepsis group was 8.2 ± 3.7 and overall was 9.8 ± 4.0. SOFA score in sepsis group was 3.0 ± 1.5, in non-sepsis group was 1.19 ± 1.15 and overall was 2.0 ± 1.6. The mean albumin/creatinine ratio (ACR) 1 and ACR2 among survivors were 150.5 ± 95.2 and 152.2 ± 87.2 and among non-survivors were 230.9 ± 43.9 and 287.8 ± 8.70, respectively. ACR2 performed similar to APACHE II in predicting mortality (difference between areas = 0.239; standard error = 0.0593 [95% confidence intervals: 0.123–0.355]; P = 0.0001). Conclusions: ACR2 had the highest value among ACR1, ACR2 and APACHE II for predicting mortality.

Vertebral osteomyelitis is a rare infection that usually affects an intervertebral disc and adjacent two vertebrae, leading to the narrowing of the space between the two vertebrae. The infection can be acute or chronic, depending on the severity of the onset of the disease. We report the case of a 37-year-old male who presented with complaints of backache, evening rise of temperature and night sweats. Magnetic resonance imaging (MRI) showed altered signal intensity in D10 to L2, with prevertebral and paravertebral soft-tissue components. Histopathological examination of image-guided biopsy specimens from this lesion showed features of the chronic non-specific inflammatory process. Culture from the sample revealed growth of Pseudomonas sp. The patient was started on intravenous ceftazidime as per sensitivity pattern which was administered for 6 Wk. The patient improved symptomatically and repeat MRI showed significant resolution of the lesions.

Background: Needle-stick injury (NSI) incidence is a major occupational hazard amongst healthcare workers (HCWs). Methods: In this retrospective study conducted amongst HCWs from October 2018 to October 2019, we aimed to know the incidence of NSI and its root cause. At the time of self-reporting of NSI, details were collected regarding mode of injury, viral markers of source and HCWs and vaccination status of HCWs. Exposed HCWs were followed up till 6 months for seroconversion. Results: A total of 47 NSIs were reported during the study period. The incidence rate per annum was 0.13. The NSI incidence was high in intensive care units (ICUs) (47%) and was commonly due to recapping needles (36.2%). Amongst 12 NSIs, sources were positive for viral markers (6 for hepatitis B virus [HBV], 5 for human immunodeficiency virus [HIV] and 1 for hepatitis C virus). Amongst four completely vaccinated HCWs exposed to HBV-positive sources, two had anti-HBV antibody titres

A 50-year-old male presented with acute urinary retention. He also had a history of cough, haemoptysis, exertional dyspnoea, loss of appetite, generalised weakness and left-ear discharge of 1-month duration. Prior episode of acute urinary retention had occurred 2 months ago; diagnostic evaluation revealed prostate abscess, and he had received treatment elsewhere for the same. He also had a history of hypertension. Physical examination revealed fever, pallor, bilateral parotid enlargement and left-ear serous discharge. Clinical examination, imaging of chest revealed consolidation with cavitation on the left side, bilateral pleural effusion. Laboratory testing revealed normocytic normochromic anaemia (haemoglobin 6.6 g/dL); neutrophilic leucocytosis (total leucocyte count 13,100 cells/mm3; polymorphs 87%); raised erythrocyte sedimentation rate (110 mm at the end of the first hour); elevated serum creatinine (2.69 mg/dL) and an active urine sediment. Flexible fibreoptic bronchoscopy showed alveolar haemorrhages. Bronchoalveolar lavage fluid Xpert MTB/RIF testing, cytopathology were negative. Computed tomography-guided biopsy from the lesion was suggestive of granulomatous vasculitis. Cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) tested positive. The patient was diagnosed to have granulomatosis with polyangitis (GPA). As arterial hypoxaemia was evident, tracheal intubation and mechanical ventilatory support were initiated. Renal replacement therapy, intravenous (iv) methyl prednisolone and cyclophosphamide pulse therapy and five sessions of plasmapheresis were administered. As remission could not be achieved, iv rituximab was started. On the 36th day of admission, the patient developed septic shock and died. The present case documents the uncommon association of GPA with prostate abscess, acute urinary retention.

A 25-year-old woman presented with a history of episodes of fever with night sweats, multiple joint pains and breathlessness for 5 months. Eight months before the present episode, she had developed a generalised rash and transient swellings in the groin on both sides. Physical examination revealed pallor, pedal oedema and a hyperpigmented rash over the chest, back and thighs. Pulse was 126 beats per minute and respirations 38/min; while breathing ambient air, the oxygen saturation by pulse oximetry was 83%. On auscultation of the chest, breath sounds were diminished bilaterally and crepitations were heard in both the lung bases. Neurological examination revealed weakness of proximal muscles of both upper and lower limbs on both sides with a power of grade 3/5. Laboratory investigations revealed elevated total leucocyte count with neutrophilic leucocytosis; band forms and metamyelocytes were seen in the peripheral blood smear. Oxygen inhalation and broad-spectrum intravenous antibiotics were initiated. Echocardiogram showed severe tricuspid regurgitation with moderate pulmonary arterial hypertension. Computed tomography (CT) of the chest revealed patchy consolidation in both the lungs, bilateral pleural effusions and pericardial effusion. Bone marrow biopsy showed normocellular normoblastic marrow with erythroid hyperplasia. 18F-fluorodeoxyglucose positron emission tomography-CT showed metabolically active lymphadenopathy both above and below the diaphragm and bilateral patchy lung infiltrates. Biopsy of the inguinal lymph node along with immunohistochemistry staining confirmed the diagnosis as T-cell lymphoma.

A 45-year-old male weaver, smoker, known case of interstitial lung disease with cor pulmonale on long-term oxygen therapy diagnosed 6 months ago who is on tapering doses of oral steroids presented to our tertiary care teaching hospital with complaints of worsened shortness of breath, cough with expectoration and fever for the past 4 days. The patient had headache, dizziness for the past 6 months. On examination, he was febrile with plethoric facies, conjunctival congestion and digital clubbing were noted. Tachycardia and tachypnoea were noted. Haemoglobin saturation on pulse oximetry was 75% while breathing on room air, 94% with 0.4 fraction of inspired oxygen. On respiratory system examination, bilateral infraaxillary crepts were present, jugular venous pressure was elevated. Remaining systemic examination was unremarkable. Investigations revealed elevated haemoglobin, elevated leucocyte count with neutrophilic leucocytosis, raised packed cell volume and red cell count. Platelet count 1.67 × 105/mm3, erythrocyte sedimentation rate 4 mm at the end of the first hour. Computed tomography (CT) of the chest (plain) showed inter and intralobular septal thickening with honeycombing in the bilateral lower lobes predominantly features suggestive of interstitial lung disease. Ultrasonography of the abdomen showed no hepatosplenomegaly. Two dimensional echocardiography was suggestive of corpulmonale. As patient had hyperviscosity symptoms due to polycythaemia and no improvement in haemoglobin with supplemental oxygen for the past 6 months, patient was further evaluated for alternate cause of polycythaemia. Serum erythropoietin (Epo) levels were normal. Arterial oxygen tension at which oxygen saturation was 50% (P50) was 28 mm Hg. Epo gene receptor mutation was positive suggestive of congenital erythrocytosis. Patient was advised long-term oxygen therapy and regular therapeutic phlebotomy to maintain haemoglobin levels and was discharged in a haemodynamically stable condition.

A 39 -year-old male, with primary hyperthyroidism for the last-3 years, for which he was not receiving any treatment, presented with complaints of sudden onset weakness in all four limbs for one day. Weakness was more in the lower limbs; and was not associated with sweating or related to a carbohydrate-rich diet. Family history, drug- history was unremarkable. On physical examination, he was anxious; exophthalmos was evident. Resting pulse rate was 112/min; rest of the general physical examination was normal. Systemic examination revealed complete absence of movement in lower limbs power 0/5 [Medical research Council (MRC) grading], but he was able to move his upper limbs against gravity 3/5 (MRC grading). Deep tendon reflexes were absent. Rest of the neurological and other systems examination were unremarkable. Laboratory testing showed hypokalemia (serum potassium 2.6 mEq/L); thyroid profile revealed TSH 0.01 mIU/L, T3 2.0ng/ml, free T4 3.3 ng/mL. A possible diagnosis of thyrotoxic periodic paralysis was considered; he was treated with intravenous correction of potassium and was started on carbimazole and propranolol. On the next 48 hours, power in all the limbs became normal and deep tendon reflexes were normally elicitable. He was asymptomatic by the third day and was discharged in a stable condition with advice to follow-up in Medicine out-patient department. Thyrotoxic paralysis is a benign condition if it is diagnosed early and treated promptly. Though it is a rare condition, it requires special mention because of its life-threatening complications. The diagnosis at initial presentation is often delayed because of the subtleness of clinical features of thyrotoxicosis.

We report a rare case of co-existence of dominant dystrophic epidermolysis bullosa (EB) and juvenile idiopathic arthritis (JIA) in an 18-year-old male patient, who is born out of consanguineous marriage. He presented with blistering skin lesions all over the body since the 2nd day after his birth, anonychia of all the toes from childhood and symmetric polyarticular inflammatory arthritis for 4 years. Erythrocyte sedimentation rate and C-reactive protein were elevated. Skin biopsy of induced vesicle was done, and histopathology showed epidermis with basket-weave hyperkeratosis, basal pigmented layer and sub-epidermal free bulla, while dermis revealed a few thin-walled proliferating capillaries with sparse lymphocytes surrounding them. Immunofluorescence showed immunoglobulin G along the basement membrane confirming the diagnosis of EB. He was diagnosed to have polyarticular rheumatoid factor-negative JIA. Treatment with oral methylprednisolone, disease-modifying anti-rheumatic drugs and intra-articular triamcinolone injections resulted in symptomatic relief of the joint pains.

Background: Sparse published data are available regarding the epidemiology of lung cancer from Rayalaseema area of Andhra Pradesh State. Methods: Consecutive patients (n = 133) diagnosed to have and treated for lung cancer in medicine and medical oncology departments at our tertiary care teaching hospital in Tirupati, South India from March 2017 to June 2018, were prospectively studied. In all patients, risk factors, clinical manifestations, method of confirmation of diagnosis and histopathological and cytopathological types were documented. Results: Their mean age was 56.4 ± 11.2 years; there were 93 (70%) males. No risk factors were evident in 110 (83%) patients. Tobacco smoking (n = 69, 52%) (all males) was the most frequently evident risk factor; other risk factors included exposure to arsenic, silicone, passive smoking, environmental exposure, old pulmonary tuberculosis. Their mean Fagerstrom score for nicotine dependence was 8.2 ± 1.7. In 17% of patients, lung cancer was incidentally detected; the remaining 83% were symptomatic. Chief presenting complaints were cough (59%), dyspnoea (50%), haemoptysis (11%), amongst others. Cytopathological and histopathological diagnosis was done in 3% and 97%, respectively. Majority (n = 123, 92%) had non-small cell lung cancer (NSCLC) (60% adenocarcinoma and 17% squamous cell carcinoma), while small cell lung cancer was evident in 10 (8%). Most of them (52%) had presented in stage 4. Conclusions: Our observations suggest that tobacco smoking still remains the most common risk factor for lung cancer; majority of the patients had NSCLC, and most patients presented late with stage 4 disease.

Adipose tissue is of two types: white adipose tissue (WAT) and brown adipose tissue (BAT). For a long time, it was considered that BAT is present only in hibernating animals and newborns, conferring them a protection from the cold environment. However, radionuclide imaging studies have shown that BAT is also present in adult human beings and plays an important role in energy metabolism. This has resulted in a resurgence of interest on BAT in the researchers. The molecular mechanisms underlying the thermogenic role of BAT and various factors that can induce the formation and activity of BAT are being explored. The thermogenic effect of BAT is mediated by uncoupling protein 1, also known as thermogenin. Several factors such as exposure to cold, stimulation by sympathetic nervous system, thyroid hormones and other endocrine factors induce brown adipogenesis and its activity. An inverse relationship exists between BAT and body weight. The increasing prevalence of obesity globally and its association with various complications makes it essential to search for therapeutic strategies to prevent and treat obesity. In this regard, BAT with its ability to dissipate energy in the form of heat appears to be a potential therapeutic target for the management of obesity.

Background: Autosomal dominant polycystic kidney disease (ADPKD) is an important cause of renal failure. Sparse recent data are available on clinical presentation ADPKD from India. Methods: We retrospectively studied the clinical presentation, imaging findings and laboratory abnormalities in 51 patients diagnosed to have ADPKD at our tertiary care teaching hospital at Tirupati, South India. Results: Their mean age at presentation was 49.1± 13.2 years; there were 32 (63%) males. Salient renal clinical manifestations at initial presentation included abdominal pain (47%); fever (35%), shortness of breath (33%); palpable mass per abdomen (25%); burning micturition (20%); haematuria (10%); and renal/ureteric caliculi (12%). Other manifestations were headache (21%); altered sensorium (12%); intracerebral bleed (8%) and chest pain (8%). Family history of ADPKD was present in 13 (26%) patients. On imaging studies kidneys were normal sized in 39%, enlarged in 59% and small sized in one patient; co-existent liver cysts were found in 12 patients. Hypertension (n = 20, 40%); chronic kidney disease (CKD) (n = 36, 71%) were evident at initial presentation. Other associated co-morbid conditions were type 2 diabetes mellitus (n = 6); Marfan's syndrome with mitral valve prolapsed and renal cell carcinoma (one patient each). Conclusions: In Tirupati, South India, ADPKD most commonly presented in fourth or fifth decade of life. Males were affected more frequently than females. Presence of CKD, hypertension at the time of inital diagnosis suggests that ADPKD is diagnosed late in the course of the disease. A high index of suspicion, specific diagnostic work-up including abdominal ultrasonography is required to diagnose ADPKD.

The use of crude leaf preparations from Carica papaya for increasing platelet count in patients with dengue fever is a popular self-treatment that is increasingly being observed recently. We report the case of a 62-year-old male who presented to our outpatient department for the evaluation of 4-day fever. In hospital diagnostic testing revealed dengue NS1 antigen enzyme-linked immunosorbent assay was positive, thrombocytopenia (platelet count 66,000/mm3), normal serum creatinine (0.96 mg/dl). Thereafter, since he was told that he was diagnosed to have dengue fever with thrombocytopenia, as per the advice given by a neighbour, he had consumed juice extracted from papaya leaves to 'increase the platelet count.' Six hours after ingestion, he had developed severe mucositis of oral cavity and severe gastritis, vomiting and loose stools. He became drowsy and irritable. Arterial blood gas analysis revealed mild metabolic acidosis, serum creatinine increased to 3.69 mg/dL. He was treated symptomatically with intravenous fluids and was carefully monitored in-hospital. Over the next 2 days, fever subsided, serum creatinine and platelet count became normal and he was discharged in a stable condition. The present case highlights the life-threatening complications that can result with the use of papaya leaf extract in the self-treatment of dengue fever.