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An inspiring doctor and scientist of great compassion and intellect, Sir David Weatherall died 8 Dec 2018. A Nuffield Professor of Medicine, founder of the MRC Weatherall Institute of Molecular Medicine and a member of Wellcome’s Board throughout the 1990s, Sir David was instrumental in the creation of MORU back in 1979.
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Credit: University of Exeter CC BY 2.0
Adverse events with ayurvedic medicines- possible adulteration and some inherent toxicities.
Ayurvedic medicine, a traditional system of medicine practiced in the Indian subcontinent is considered to be devoid of adverse events. We report three cases which highlight the possibility of adverse events related with the use of ayurvedic products. A 35 year old woman with hepatitis took ayurvedic powder medicine and swarnabhasma (gold salt) and had her liver injury worsened, possibly due to alkaloids, and developed nephrotic syndrome, possibly due to gold salt. A 57 year old hypertensive man was taking ayurvedic medicine containing reserpine which had long been withdrawn from the allopathic system of medicine due to wide range of side effects. A 47 year old woman with rheumatoid arthritis was taking an unknown tablet containing steroid as an adulterant for 2 years and developed side effects typical of steroid excess. We would like to highlight the fact that ayurvedic medicines do have propensity to cause adverse events due to adulteration or inherent constituents like alkaloids, and hence may not always be completely safe.
Chronic Cavitary Pulmonary Aspergillosis: Complication of Pulmonary Tuberculosis.
Pulmonary Aspergillosis is a fungal infection of the lungs that can lead to invasive disease and the formation of cavities, especially in the immunocompromised population. The most common clinical features are no symptoms at all to fever, cough, nondescript chest discomfort, trivial hemoptysis, and shortness of breath. Most patients respond well to Itraconazole therapy. Pulmonary Tuberculosis is one of the conditions that can lead to Aspergillosis, especially in cavities that are formed by Mycobacteria; both often manifest with similar clinical features and lead to diagnostic error. We present a case of a 28-year-old male diagnosed with pulmonary tuberculosis who developed symptoms of persistent cough, hemoptysis, increasing fatigue, and weight loss despite compliance with antitubercular therapy. Ultimately diagnosis of Cavitary pulmonary aspergillosis was made on clinical, laboratory, and radiological grounds. In a patient presenting with worsening symptoms of tuberculosis, there should be a suspicion of aspergillosis, necessitating the performance of standard fungal infection investigations. Keywords: Immunocompromise iosts; lung cavity; pulmonary aspergillosis; tuberculosis.
Case Report: Anti-MDA-5 dermatomyositis in a resource-limited setting.
Anti-Melanoma Differentiation-Associated gene 5 (Anti-MDA-5) dermatomyositis is a rare subtype of inflammatory myopathy characterized by unique skin lesions, rapidly progressive interstitial lung disease, and skeletal muscle inflammation. It has a high mortality rate in the absence of early treatment. However, diagnosis of this entity is challenging in a country like Nepal because of various constraints such as lack of expert rheumatologists and resource limitations. Here we describe a case of one patient who had presented to us with generalized weakness, cough and shortness of breath who was finally diagnosed as anti-MDA-5 dermatomyositis. He responded to combination of immunosuppressives and is currently doing well. This case highlights the diagnostic and therapeutic challenges in managing such cases in a resource-limited setting.
Case Report: Paraquat poisoning
Paraquat (1, 1′-dimethyl-4,4′-bipyridinium) is a commonly used herbicide that is highly toxic when ingested. Ingestion of toxic doses of paraquat has serious complications on the lungs, gastrointestinal tract, kidney, liver, and other organs. Due to its inherent toxicity and the lack of a specific antidote, it has a high case fatality rate. Despite being restricted to commercially licensed users in Nepal, it is a common herbicide causing both intentional and accidental poisoning. Although there have been numerous anecdotal cases of paraquat poisoning in Nepal, no reports have been published in the literature. . We report a case of a 30-year old female, who developed gastrointestinal symptoms like vomiting, diarrhoea and odynophagia, renal and liver injury after accidental ingestion of 10ml of 20% paraquat. Symptoms and organ involvement subsided with timely and appropriate supportive management.
Dengue and scrub typhus co-infection causing septic shock.
A 33-year-old female presented with a history of high-grade fever, cough, dyspnea, joint pain and myalgia. On examination, the patient was febrile with tachycardia, hypotension and decreased oxygen saturation. Chest auscultation revealed bilateral decreased air entry with crepitation supported by bilateral pulmonary infiltrates on chest X-ray. The laboratory investigations showed leukocytosis, thrombocytopenia, transaminitis and renal impairment. The patient was treated with intravenous fluids, ceftriaxone and levofloxacin; however, there was no clinical improvement till 48 h. She was then diagnosed with scrub typhus and dengue co-infection via serologies. Doxycycline was started following which the patient improved in 24 h. Scrub typhus can present with septic shock but does not respond to the usual antibiotics and the addition of doxycycline will result in rapid clinical improvement. Co-infection with other tropical diseases such as dengue is also common, hence it is important to test based on local endemicity.
Case Report: Using basic liver function tests as a guide to suspected Wilson's disease.
We present a case of a 36-year-old female patient who presented with subacute liver disease with a history of alcohol abuse. On basic liver function tests (LFT), she had aspartate transaminase / alanine transaminase > 2.2 and alkaline phosphatase / total bilirubin < 4. This pattern in acute liver failure patients signifies Wilson's disease. Its presence in our patient with subacute liver disease also prompted us to suspect Wilson's disease and we extended the liver disease screen to include slit lamp eye examination for Kayser-Fleischer rings, serum ceruloplasmin and 24-hour urinary copper level, which led to the diagnosis. She improved clinically and biochemically with zinc acetate therapy. As screening for rare diseases is not always possible in low-income countries, this case demonstrates the usefulness of the basic LFT as a guide for suspecting Wilson's disease in patients with liver disease.
Case Report: Co-existence of sarcoidosis and Takayasu arteritis
Takayasu arteritis is a rare systemic large vessel vasculitis affecting the aorta and its branches. Sarcoidosis, too, is an inflammatory disease. Both entities are granulomatous conditions with a questionable association in their etiopathogenesis. Only a few cases of their coexistence have been reported in the literature. To our knowledge, no such cases have been reported from Nepal. We report a Nepalese woman who presented with non-productive cough, progressive shortness of breath and chest tightness of 3 years duration. She had a history of recurrent bilateral granulomatous uveitis over the previous 3 years. Examination revealed clubbing of digits, absent pulses over the left radial, ulnar and brachial arteries, and a weak pulse over the right arm including the bilateral carotid arteries. Pulmonary function test showed restrictive pattern, a high-resolution computed tomography (HRCT) scan of the chest revealed findings suggestive of pulmonary sarcoidosis. A CT angiogram suggested large vessel vasculitis. Bronchoscopy with biopsy revealed granulomatous inflammation, negative for malignancy and tuberculosis. She was hence, diagnosed with co-existing Takayasu arteritis and sarcoidosis, and treated with Prednisolone 60 mg once daily with dramatic improvement over 4 days and was discharged stable on domiciliary oxygen. She is currently on azathioprine 50 mg, prednisolone 10 mg without the need for supplemental oxygen. This case report highlights the importance of a proper physical examination as a guide to the use of modern technology in making a correct diagnosis. Furthermore, in countries where tuberculosis is endemic, it should always come as the most important differential diagnosis of granulomatous inflammation.
Case Report: Cryptococcal meningitis in an apparently immunocompetent patient in Nepal - challenges in diagnosis and treatment.
A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for Cryptococcus in the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due to financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal.
Case Report: Pulmonary tuberculosis and raised transaminases without pre-existing liver disease- Do we need to modify the antitubercular therapy?
We report a case of an adult female with pulmonary tuberculosis who had biochemical evidence of liver injury during the presentation manifested as raised transaminases, but without clinically obvious pre-existing liver disease nor a history of hepatotoxic drug use. This is a fairly common scenario seen in tuberculosis endemic areas; however, this is an under reported condition in the literature and guidelines for its management has not been established. Many clinicians including the authors have treated such cases with modified liver friendly regimens in fear of increasing the hepatotoxicity with standard antitubercular drugs. However, the modified regimens may not be optimal in treating the underlying tuberculosis. In this report, we gave full dose standard drugs, and the liver injury resolved as evidenced by normalization of transaminases. Further research is required in this regard, but the presence of transaminitis with no obvious common underlying etiology may not warrant a modification of standard antitubercular regimen.
Case Report: Co-existence of sarcoidosis and Takayasu arteritis.
Takayasu arteritis is a rare systemic large vessel vasculitis affecting the aorta and its branches. Sarcoidosis, too, is an inflammatory disease. Both entities are granulomatous conditions with a questionable association in their etiopathogenesis. Only a few cases of their coexistence have been reported in the literature. To our knowledge, no such cases have been reported from Nepal. We report a Nepalese woman who presented with non-productive cough, progressive shortness of breath and chest tightness of 3 years duration. She had a history of recurrent bilateral granulomatous uveitis over the previous 3 years. Examination revealed clubbing of digits, absent pulses over the left radial, ulnar and brachial arteries, and a weak pulse over the right arm including the bilateral carotid arteries. Pulmonary function test showed restrictive pattern, a high-resolution computed tomography (HRCT) scan of the chest revealed findings suggestive of pulmonary sarcoidosis. A CT angiogram suggested large vessel vasculitis. Bronchoscopy with biopsy revealed granulomatous inflammation, negative for malignancy and tuberculosis. She was hence, diagnosed with co-existing Takayasu arteritis and sarcoidosis, and treated with Prednisolone 60 mg once daily with dramatic improvement over 4 days and was discharged stable on domiciliary oxygen. She is currently on azathioprine 50 mg, prednisolone 10 mg without the need for supplemental oxygen. This case report highlights the importance of a proper physical examination as a guide to the use of modern technology in making a correct diagnosis. Furthermore, in countries where tuberculosis is endemic, it should always come as the most important differential diagnosis of granulomatous inflammation.