Biomedical subjects
Publications and source records attributed to S Bhadada.
Incidental detection of pituitary metastasis in patients with primary breast carcinoma is not uncommon. However, pituitary metastasis manifesting as bitemporal hemianopia as a presenting manifestation in a patient with silent adenocarcinoma of the lung, that too in a women, is quite uncommon. We report such a case.
BACKGROUND: Among the parathyroid imaging techniques, ultrasonography (USG) has the advantage of convenience, easy availability and low cost. OBJECTIVE: To study the role of USG in localization (side and/or site) of abnormal parathyroid glands in primary hyperparathyroidism (PHPT) and to compare with radionuclide scintigraphy and the 'gold standard', surgery. METHODS: Forty-six consecutive patients undergoing USG of the anterior neck for a diagnosis of PHPT in whom a nuclear scan (technetium-99m sestamibi and/or thallium-201/technetium-99m pertechnetate scintigraphy) was also performed, were studied. The results of imaging were independently interpreted and correlated with reference to surgical findings. RESULTS: Forty-six patients had 52 abnormal parathyroid glands on surgical exploration and surgery was successful in all but one. Forty-one patients had a single adenoma, four had multigland disease and one had a paraganglioma. USG correctly localized the abnormal gland in 30 (73%) and scintigraphy was positive in 40 (98%) out of 41 patients with a single adenoma as confirmed on surgical exploration. Scintigraphy showed a positive concordant test in all 30 patients with a single abnormal gland detected on USG and picked up 10 out of 11 abnormal glands where USG was negative. The sensitivity and positive predictive value of USG for detecting a single abnormal gland was 73% and 100%, respectively, whereas the sensitivity and positive predictive value for scintigraphy was 98%. In patients with multigland disease, USG missed 3 (30%) out of 10 and scintigraphy missed 6 (60%) out of 10 abnormal parathyroid glands as confirmed on surgical exploration (P < 0.05). However, in two patients who had ectopic parathyroid gland, both the modalities localized the lesion in one (paraganglioma), whereas in the other neither test was helpful (left retro-esophageal). CONCLUSION: USG is a convenient, affordable and useful modality to localize abnormal enlarged parathyroid glands in the majority of patients with PHPT. However, when USG is negative, scintigraphy is complementary to it.
OBJECTIVE: To analyze the clinical profile of juvenile hyperthyroidism at presentation, their treatment outcome; predictors of remission and relapse. METHODS: Retrospective analysis of medical records of 56 patients with juvenile hyperthyroidism seen over a period of 16 years. A cohort of 38 females and 18 males with mean (+/-SD) age of 14.9 +/- 3.4 years (range 3 to 18 years) was analyzed. RESULTS: Majority of patients was in the age group of 12-16 years. Common symptoms observed at presentation were weight loss (82.1%), excessive sweating (78.6%), heat intolerance (76.8%), increased appetite (73.2%) and diarrhea in 48.2%. In addition, accelerated linear growth was observed in 7.1% of patients. Goiter was present in 98.2% of children; 94.5% of which was diffuse and 4.8% was multinodular. The mean ((+/-SD) T3 was 4.8 +/- 3.4 ng/mL (N, 0.6-1.6), T4 was 218 +/- 98 ng/mL (N, 60-155) and TSH was 0.44 +/- 0.36 (N, 0.5-5.5 microIU/mL). TMA positivity seen in 36.9% of patients. All patients were treated with carbimazole; subsequently 4 patients required thyroidectomy and one required radioactive iodine ablation. Mean (+/-SD) duration of follow-up in our patients was 4.9 +/- 3 years, ranging between 1.6 to 16 years and mean (+/-SD) duration of treatment was 34.4 +/- 22.6 months (range 12 to 120 months). Mean (+/-SD) duration to achieve euthyroidism was 5.2 +/- 4.7 months, ranging between 1-33 months. On intention to treat analysis, remission with carbimazole was achieved in 47.6%, remaining patients failed to achieve remission with drug treatment. CONCLUSION: Graves disease is the commonest cause of juvenile hyperthyroidism. Carbimazole is safe, effective, cheap, and easily available form of therapy. It is occasionally associated with serious side effects but requires prolonged follow up.
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OBJECTIVE: Paget's disease of bone has been described as a few case reports from India. The aim of the present study is to document the existence of Paget's disease (PD) in India. MATERIAL AND METHODS: We describe demography, clinical manifestations, biochemical and radiological profile and the treatment outcome of 21 patients of PD. RESULTS: Mean (+/-SD) age of these patients at presentation was 49.2 +/- 17.6 years and the male to female ratio was 2.5:1. Common clinical manifestations included backache, headache and bone pains. Others were fracture, joint pain, deafness, gait ataxia, visual impairment and difficulty in biting. Two patients presented with hydrocephalus and one had recurrent paraparesis. Fifteen (71.4%) patients had polyostotic and six (28.6%) had monoostotic Paget's disease. More commonly involved bones were skull and spine (61.9%) followed by pelvis (38.1%), femur (33.3%), tibia (9%) and ulna (9%). Mean (+/-SD) serum alkaline phosphatase at diagnosis was 1514 +/- 1168 IU/L and nine months after treatment with bisphosphonates decreased to 454 +/- 406 IU/ L(P<0.03). CONCLUSION: This illustrates that Paget's disease does exist in India and a high index of suspicion is required to clinch the diagnosis.
AIMS: Body mass index (BMI) has been considered as a gold standard for defining overweight and obesity, and in western populations it has correlated with percentage body fat (%BF). However, data in native Asian Indians regarding BMI and %BF is conflicting and questions have been raised to redefine the BMI cut-off values in these subjects. SUBJECTS AND METHODS: 150 healthy volunteers (79 men and 71 women aged 18-78 and 23-75 years respectively) were recruited for the study. Clinical examination was performed to exclude any systemic disease. Anthropometric measurements were done and %BF was calculated from skinfold thickness. RESULTS: The BMI for men was 24.96 kg/m(2) (+/-3.85) and for women was 25.75 kg/m(2) (+/-4.39).%BF calculated by skinfold thickness was 21.94% (+/-5.92) in men and 35.15% (+/-5.77) in women. Receiver operating characteristic curve analysis showed a higher sensitivity (92%) and higher negative predictive value (95%) for the conventional cut-off value of the BMI (25 kg/m(2)) in identifying subjects with overweight with %BF of more than 25% in men. However, in females a BMI of 23.9 kg/m(2) had a sensitivity of 84% and negative predictive value of 62% thereby decreasing the misclassification by 13% with %BF of more than 30% as compared to conventional BMI cut-off of >25 kg/m(2). A comparison of BF data amongst Caucasians, Blacks and migrant ethnic Asians revealed inconspicuous differences in men. CONCLUSION: Native North Indian men had comparative BMI and %BF as that of their western counterparts.
AIM: To describe the presentation and outcome of rhino-orbital-cerebral mucormycosis (ROCM) in adolescents with type 1 diabetes mellitus (T1DM). METHODS: The medical records of six patients of T1DM with ROCM admitted between October 2001 to January 2004 were analysed. RESULTS: The mean (+/- SD) age and duration of DM of these patients were 16.1+/-3.0 years and 26.3 +/- 24.9 months respectively. Four patients had ROCM at presentation, while two developed it during their hospital stay when recovering from diabetic ketoacidosis. Proptosis (100%) and ptosis (100%) were the most common symptoms, and ophthalmoplegia (85%) and vision loss (85%) were the most common signs. Maxillary sinus (85%) was the commonest paranasal sinus to be involved. All patients received amphotericin B and had appropriate surgery except one. Four patients survived. Patients who had altered sensorium, facial necrosis, palatal perforation and cerebral involvement at presentation had poor outcome. CONCLUSION: High index of suspicion of ROCM in T1DM and combined approach with amphotericin B and appropriate surgery is rewarding.
This study was conducted to assess the influence of dopamine on thyrotropin secretion in patients with primary hypothyroidism before and after optimized L-thyroxin replacement therapy. Thyrotropin responses to dopamine infusion (4 microg/kg/min over 3 hours) and IV metoclopramide (10 mg bolus), a dopamine receptor blocker were studied in 25 consecutive patients with primary hypothyroidism before and after achieving stable euthyroid state and compared with 15 normal age-matched controls. Thyrotropin response to both dopamine infusion (decremental) and IV metoclopramide bolus (incremental) was greater in patients with primary hypothyroidism than that in the control subjects. Thyrotropin response was greater in women than in men. The magnitude of decremental thyrotropin response to dopamine infusion and the incremental response to IV metoclopramide bolus significantly correlated with the basal T3 and T4 levels. Thyrotropin response was blunted to dopamine infusion but not to metoclopramide at follow-up after six-month replacement with L-thyroxin, and both the responses were comparable in women and men in patient group. We conclude that modulation of dopaminergic system by dopamine or by dopamine receptor blocker has a greater influence on thyrotropin secretion in patients with primary hypothyroidism than euthyroid normal subjects.
Emphysematous cystitis (EC) and emphysematous myositis (EM) are rare disorders and concurrent occurrence of both in a patient with type 2 diabetes has not been reported previously. We report a patient who presented with pneumaturia and later with pain in thigh and diagnosed of both concurrently.
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Concurrence of emphysematous pyelonephritis and emphysematous cholecystitis in a patient with type 2 diabetes has not been reported in the published literature, to the authors' knowledge. A patient who had both at the time of presentation is reported. The mechanism of gas formation and the management strategies are discussed.
AIM: To report presentation and outcome of rhino-orbital-cerebral mucormycosis (ROCM) exclusively in patients with diabetes mellitus. METHODS: Retrospective, non-comparative, interventional analysis of the medical records of 35 patients with ROCM among 22 316 patients with diabetes seen over the last 12 years. RESULTS: A cohort of 23 men and 12 women with a mean (SD) age of 47.3 (14.4) years (range 18-70 years) was studied. Five patients had type 1 diabetes mellitus, 29 had type 2 diabetes mellitus, and one had secondary diabetes. Nine patients had ROCM as the first clinical manifestation of diabetes. The mean (SD) blood glucose at presentation was 20.6 (8.3) mmol/l (range 10.0 to 53.3 mmol/l) and 17 patients had ketosis/ketoacidosis. Ophthalmic symptoms and signs were pronounced: external ophthalmoplegia (89%), proptosis (83%), visual loss (80%), chemosis (74%), and eye lid gangrene (14%). Non-ophthalmic manifestations included sinusitis (100%), nasal discharge/ulceration (74%), infranuclear VI nerve palsy (46%), palatal necrosis (29%), cerebral lobe involvement (20%), and hemiparesis (17%). Computed tomography/magnetic resonance imaging showed involvement of paranasal sinuses in all patients with ethmoid (86%) and maxillary (80%) sinuses being most frequently involved. Orbital involvement was observed in 80% of patients with cavernous sinus thrombosis in 11%, and internal carotid occlusion and hydrocephalus in 3% each. All were treated with amphotericin B (3-3.5 g) and 26 (74%) patients underwent appropriate surgery. Twenty one patients (68%) survived with a mean (SD) follow up of 39.6 (34.1) months (range 10 months to 11 years). Factors related to poor survival included delay in diagnosis and treatment (p<0.05), facial and/or eye lid gangrene (p<0.05), hemiplegia (p<0.05), cerebral invasion by mucorales (p<0.05), and treatment with amphotericin B alone (p<0.05). CONCLUSIONS: In patients with diabetes and ROCM, ROCM was the presenting manifestation in one fourth of the patients. Ophthalmic and extensive cerebral involvement predominated in the clinical picture. Delay in treatment due to late presentation and associated complications were major determinants of the survival outcome in these patients.
A young boy with periarticular nodules and discharging sinuses diagnosed as tumoral calcinosis is described. The case is reported to highlight its rarity and low index of suspicion for this disease. Mechanisms of these solid tumours deposits and their management are discussed.
BACKGROUND & OBJECTIVES: Structural and/or functional alterations in adrenal glands have been reported in human immunodeficiency virus (HIV) infection. However, no information has been reported from India. Hence a study was undertaken to assess the basal and circadian variations in plasma cortisol, and cortisol response to bolus ACTH in patients with AIDS. METHODS: Basal and stimulated plasma cortisol levels at 0800 h and 1600 h and, at 30 and 60 min following an intravenous bolus of 250 micrograms ACTH (short synacthen test, SST) were estimated in 15 patients with AIDS (CD4 < or = 200/microliter) and 12 healthy controls. The nature of the opportunistic infections and/or associated disease in each patient was also studied. RESULTS: The patients had higher median basal plasma cortisol levels as compared to the controls at 0800 h (540 nmol/l vs 415 nmol/l, P < 0.005) and at 1600 h (420 nmol/l vs 285 nmol/l, P < 0.003). Five patients (33%) exhibited abnormal circadian cortisol rhythms. All subjects in the control group and all but one (6.6%) in the patients group had normal peak plasma cortisol response (> or = 550 nmol/l) to SST. The lone patient with subnormal cortisol response had no feature of adrenal insufficiency. On the contrary, 3 patients clinically suspected to have adrenal insufficiency, had normal plasma cortisol response. INTERPRETATION & CONCLUSIONS: These findings suggest that most patients with AIDS have elevated basal plasma cortisol levels with abnormal circadian rhythm in some and normal adrenocortical reserve irrespective of the symptoms/signs of adrenal insufficiency.
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