Chylothorax due to tuberculosis

CASE REPORT

Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 145-148

Left-sided chylothorax due to tuberculosis in an adult

K Gowrinath, KR R. Umamahesh
Department of Pulmonary Medicine, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication

8-Apr-2019

Correspondence Address:
K Gowrinath
Department of Pulmonary Medicine, Apollo Speciality Hospital, Nellore - 524 004, Andhra Pradesh, 
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCSR.JCSR_44_18

Abstract

A spontaneous chylothorax is rare. Chylothorax as a manifestation of tuberculosis (TB) is very rare even in countries where TB is endemic. We report a case of left sided chylothorax due to TB in a 50-year-old male alcoholic who presented with hypotension and hyponatremia. TB was diagnosed through histopathological examination of mediastinal lymph node biopsy. Initial conservative treatment with four days of tube thoracostomy drainage was effective but chylothorax recurred one week later after starting anti-TB drugs. Resolution of chylothorax was achieved with repeat tube thoracostomy drainage for four weeks and daily anti-TB therapy with isoniazid, ethambutol, rifampicin and pyrazinamide for two months followed by daily isoniazid and rifampicin for four months. Patient recovered well and chylothorax did not recur during the follow up period of three months.

Keywords: Chylothorax, hyponatremia, tube thoracostomy, tuberculosis

How to cite this article: Gowrinath K, R. Umamahesh K R. Left-sided chylothorax due to tuberculosis in an adult. J Clin Sci Res 2018;7:145-8

How to cite this URL: Gowrinath K, R. Umamahesh K R. Left-sided chylothorax due to tuberculosis in an adult. J Clin Sci Res [serial online] 2018 [cited 2019 Apr 9];7:145-8. Available from: http://www.jcsr.co.in/text.asp?2018/7/3/145/255668

Introduction

Chylothorax (accumulation of chyle in the pleural cavity) is rare and results from localised damage or blockage of thoracic duct or its lymphatic tributaries in the thorax and characterised by elevated triglycerides and presence of chylomicrons.^[1] Malignancy is the most common cause of spontaneous chylothorax and depending on the location of thoracic duct obstruction or leak, 50% occur in the right hemithorax, 33.3% in the left side and 16.66% in both hemithoraces.^[2] Tuberculosis (TB), as the cause of chylothorax, is rarely reported even in hyperendemic countries such as India. There is no standardised management regarding TB-associated chylothorax; some cases were treated effectively with medical treatment alone, while in other cases, early surgery was done with quick recovery.^[3] We report a unique case of left-sided chylothorax due to TB in an adult who presented with hypotension and hyponatremia.

Case Report

A 50-year-old male was admitted for progressive breathlessness, weakness and decreased appetite for 15 days. There was no history of cough, chest pain or fever. The patient had a history of diabetes mellitus and hypertension with dilated cardiomyopathy. The patient was a non-smoker but had a history of regular alcohol consumption for 25 years. On physical examination, the patient was thinly built with signs of mild dehydration and had bilateral pitting pedal oedema. Pulse rate was 146/min, blood pressure was 84/60 mmHg and room air oxygen saturation was 90%. Respiratory system examination showed the features of left-sided pleural effusion. A posteroanterior chest radiograph [Figure 1] showed a large left-sided pleural effusion and patchy opacities on the right side. Urinalysis showed proteinuria and blood examination showed a total leukocyte count of 8.700/mm³ with normal differential, total protein of 6.0 g/dL (albumin of 2.8 g/dL), sodium of 121 mEq/L and random blood sugar of 224 mg/dL. A diagnostic pleural tap revealed freely flowing milky fluid [Figure 2]. Empyema was ruled out after the tested pleural fluid remained opalescent at the end of centrifugation, and pseudochylothorax was excluded after opalescence of pleural fluid cleared with addition of 2 ml of ethyl ether. Pleural fluid analysis showed a total of 930 cells with 96% lymphocytes, protein of 6.6 g/dL, lactate dehydrogenase of 118 U/L (serum level of 224 U/L), triglycerides of 478 mg/dL (serum triglycerides of 154 mg/dL) and cholesterol of 58 mg/dL (serum cholesterol of 166 mg/dL). All pleural fluid smears and cultures were negative. Ultrasound abdomen was normal except for a small umbilical hernia. Tube thoracostomy was done and approximately 2 L of pleural fluid [Figure 3] drained within 24 h. Induced sputum reports were negative and the patient declined to undergo flexible bronchoscopy. The patient was managed with total parenteral nutrition and hyponatremia was corrected with intravenous administration of hypertonic saline. The chest tube was removed after 4 days as pleural drainage ceased. Positron-emission tomography-computed tomography (PET-CT) [Figure 3] showed generalised lymphadenopathy [Figure 3], including mediastinal, retrocrural and retroperitoneal groups. Mediastinal lymph node biopsy was done through mediastinoscopy and histopathological examination revealed granulomatous inflammation with central caseation. The patient was started on anti-TB treatment with daily isoniazid, rifampicin, ethambutol and pyrazinamide. After 4 weeks, the patient returned to us with a recurrence of chylothorax and repeat tube thoracostomy was done. The patient was not willing for surgery and was discharged with chest tube in situ. Daily pleural drainage remained 100–200 mL and chest tube was removed at 4 weeks after the pleural drainage ceased and reexpansion of the left lung was maintained. Anti-TB therapy was continued with daily isoniazid, rifampicin, pyrazinamide and ethambutol for the first 2 months, followed by 4 months of daily isoniazid plus rifampicin. Chest radiograph [Figure 4] done at the end of 6 months of treatment revealed clearance of chylothorax and alveolar opacities in the right lung. The patient is currently doing well during the follow-up of 3 months.

Figure 1: A posteroanterior chest radiograph showing a large left-sided pleural effusion and patchy opacities on the right side Click here to view

Figure 2: Clinical photograph showing milky pleural fluid in the pleural drainage system Click here to view

Figure 3: Positron-emission tomography-computed tomography showing generalised lymphadenopathy Click here to view

Figure 4: Post-treatment chest radiograph showing complete resolution of chylothorax and alveolar opacities on the right side Click here to view

Discussion

Thoracic duct arises from cisterna chyli at the level of second lumbar vertebral body and ascends between the aorta and azygos vein in the posterior mediastinum through the aortic hiatus of the diaphragm up to the level of fifth thoracic vertebra and then turns to the left side crossing the vertebral column before ending with an opening between the junction of left subclavian and left internal jugular vein.^[4] Thoracic duct transports digestive fat (chyle) from the intestines and hepatic lymphatics into the venous system at the rate of 10–100 ml/kg depending on the diet, intestinal absorption and the nature of the physical activity.^[5] Chyle is formed in the intestines and flows through lymph channels into the cisterna chyli. The colour of chyle relies upon the person's nutritional status and is usually milky, odourless, alkaline and sterile. Chyle is composed of proteins, lipids, lymphocytes, immunoglobulins, fat-soluble vitamins, electrolytes and water. Hence, loss of chyle and lymph into pleural space may cause malnutrition, hyponatremia, acidosis and hypocalcaemia in advanced cases.^[6] Immunodeficiency may develop if there is continued loss of lymphocyte-rich chyle. Our case presented with mild dehydration, hypoproteinaemia and hyponatremia. The detection of chylomicrons in the pleural fluid and pleural fluid triglyceride level of >110 mg/dL are diagnostic of chylothorax and our case fulfilled both diagnostic criteria. The pathogenesis of chylothorax secondary to TB is still not clear and postulated to occur either due to extrinsic compression of thoracic duct causing increase in pressure in the surrounding lymphatic system and resulting leakage of chyle into pleural space or direct involvement of thoracic duct by the TB of adjacent mediastinal lymph nodes.^[7] Lymphangiography can identify the cause and defect of the site and size of leak from the thoracic duct. However, we do not have this facility in our hospital. Left-sided chylothorax in our case could be due to enlarged mediastinal lymph nodes compressing the thoracic duct above the level of the fifth thoracic vertebra. PET-CT in our case was justifiable as malignancy is the most frequent cause of spontaneous chylothorax. Review of Indian literature showed a case of bilateral chylothorax showing culture positivity for mycobacterial TB along with cervical and abdominal lymphadenopathy and medical treatment without tube thoracostomy was effective.^[8] In another recent publication of right-sided chylothorax, biopsy of mediastinal lymph node through mediastinoscopy established tuberculous aetiology, and medical therapy was successful.^[9] A moderate left-sided chylothorax in an AIDS patient was successfully treated with anti-TB treatment alone, and CT scan showed enlarged retrocrural lymph node compressing the cisterna chyli.^[10] In our case, the PET-CT scan showed enlarged mediastinal and retrocrural lymph nodes; however, the exact site of thoracic duct involvement was not detected. In a recent review of 37 cases of TB-associated chylothorax,^[11] 45.9% had disseminated TB, and 72.2% of cases were diagnosed through the microbiologic tests. Conservative management with anti-TB therapy was effective in 94.4% of cases and only 17.1% required thoracic duct ligation and use of octreotide. In our case, there were lung infiltrations and generalised lymphadenopathy. Pulmonary TB could not be evaluated properly as there was no cough, induced sputum reports were inconclusive and the patient refused flexible bronchoscopy.

The most important treatment option in spontaneous chylothorax is to identify and treat the underlying cause. Recently, an algorithm of stepwise management of chylothorax has been proposed,^[12] in which initial conservative management includes proper fluid and electrolyte replacement; dietary modifications such as non-fat diet, medium-chain triglyceride diet and bowel rest along with total parenteral nutrition; use of drugs such as somatostatin or octreotide or etilefrine to reduce the production of chyle and drainage of chylothorax with thoracentesis or tube thoracostomy to improve symptoms and pleurodesis if the above methods fail. Surgical treatment is by thoracic duct ligation through minimally invasive video-assisted thoracoscopic surgery or open surgical approach. In high-output chylothorax, percutaneous image-guided thoracic duct embolisation may be an effective alternative treatment option. If high-output pleural drainage still persists, pleuroperitoneal or pleurovenous shunt may be done as last resort. In adults, surgical management is recommended when pleural drainage persists beyond 2 weeks or there is a continuous pleural accumulation of chyle despite tube thoracostomy drainage and if there are complications due to nutritional deficiency or metabolic derangement.^[13] Our patient refused surgery and preferred tube thoracostomy drainage at home along with anti-TB treatment. In our case, pleural drainage of chyle was approximately 100–200 mL/day and ceased completely at 4 weeks. We are not aware of any previous report of TB-associated chylothorax with similar therapeutic experience in English literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

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6.	Servelle M, Noguès C, Soulié J, Andrieux JB, Terhedebrugge R. Spontaneous, post-operative and traumatic chylothorax. J Cardiovasc Surg (Torino) 1980;21:475-86.
7.	Grobbelaar M, Andronikou S, Goussard P, Theron S, Mapukata A, George R, et al. Chylothorax as a complication of pulmonary tuberculosis in children. Pediatr Radiol 2008;38:224-6.
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9.	Amar JB, Zaibi H, Dahri B, Aouina H. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis. Indian J Tuberc 2017;64:141-3.
10.	Bielsa S, Pardina M, Porcel JM. Chylothorax due to enlarged tuberculous lymph nodes. BMJ Case Rep 2014;2014. pii: bcr2014204582.
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12.	Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg 2016;49:18-24.
13.	Talwar A, Lee HJ. A contemporary review of chylothorax. Indian J Chest Dis Allied Sci 2008;50:343-51.

Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

Unilateral graves' disease

: The lesser known
Ranadheer Gupta Manthri, Nimmagadda Ajit, Suresh Vaikakkara, B Vijayalakshmi Devi, Tekchand Kalawat

Indian Journal of Nuclear Medicine 2019 34(2):96-98

Background: Here, we present a retrospective study conducted from 2009 to 2018, which showed the presence of unilateral uptake of radioactive tracer on 99mTc thyroid scintigraphy scan in 15 patients with Graves' disease. Materials and Methods: All these patients had either clinical features of Graves' disease or elevated thyroid hormone levels along with ultrasonographic features, showing either normal thyroid gland or diffuse thyroiditis. The scintigraphic features revealed increased uptake in one lobe of the thyroid gland with the other lobe being normal. Results: Of the 15 patients, 13 were females and two were males. The mean age of the patients was 47 years with standard deviation of 3.4 years (range 26–70 years). Eight of the 15 patients had increased uptake on the right lobe and seven had increased uptake in the left lobe. Conclusion: This study shows that there exists an entity called unilateral Graves' disease which should be further evaluated. 

Myocardial ischemia detection in high-risk asymptomatic patients: Coronary calcium score,High-sensitivity C-reactive protein,Single-photon emission computed tomography

Single-photon emission computed tomography myocardial ischemia detection in high-risk asymptomatic patients: correlation with coronary calcium score and high-sensitivity C-reactive protein
Irena Mitevska, Elizabeta Srbinovska, Lily Stojanovska, Emilija Antova, Vasso Apostolopoulos, Marijan Bosevski

Indian Journal of Nuclear Medicine 2019 34(2):99-106

Background: The association between myocardial ischemia in high-risk patients with coronary calcium score (CCS) and high-sensitivity C-reactive protein (hs-CRP) is not well established. Aims: We evaluated the correlation between hs-CRP, CCS, and myocardial ischemia in asymptomatic high-risk patients without known coronary artery disease (CAD). Materials and Methods: We prospectively assessed 68 asymptomatic high-risk outpatients without known CAD. One-day rest-stress Tc-99m single-photon emission computed tomography (SPECT) myocardial perfusion imaging and multislice computed tomography were performed. Multivariate regression analysis was performed for the assessment of predictors of myocardial ischemia. Standard risk factors and hs-CRP values were analyzed. Results: CCS >0 Agatston score was observed in 26 patients (46.4%). Seven patients had CCS between 10 and 99 AU, 8 patients between 100 and 400 AU, and 11 patients had CCS >400 AU. Mild ischemia was noted in 11 patients, moderate ischemia in 10 patients, and severe ischemia in 6 patients. Hs-CRP was >1 mg/L in 39 patients, of whom 8 patients had CCS >0, 13 patients had normal SPECT results, 6 patients had mild ischemia, and 12 patients had moderate and severe ischemia. Multivariate regression analysis showed independent predictors for increased CCS: low-density lipoprotein cholesterol (odds ratio [OR]: 2.891; P = 0.001); age >70 years (OR: 2.568; P = 0.001); and smoking (OR: 1.931; P = 0.001). We found hs-CRP to be an independent predictor of myocardial ischemia (OR: 4.145; 95% confidence interval: 1.398–7.471, P = 0.001). Conclusion: hs-CRP was an independent predictor of myocardial ischemia. hs-CRP might improve the selection of high-risk asymptomatic patients for myocardial SPECT imaging. 

Thyroid-stimulating hormone (TSH)-stimulated thyroglobulin (sTg) measurements by the end of the 1st-year postablation in differentiated thyroid cancer (DTC)

Value of the postablative thyroglobulin measurements for assessment of disease-free status in patients with differentiated thyroid cancer
Nahla Dessoki, Ibrahim Nasr, Ahmed Badawy, Ismail Ali

Indian Journal of Nuclear Medicine 2019 34(2):118-124

Aim: The aim of the study is to evaluate the value of thyroid-stimulating hormone (TSH)-stimulated thyroglobulin (sTg) measurements by the end of the 1st-year postablation in differentiated thyroid cancer (DTC) patients with biochemical non complete response (indeterminate and incomplete response). Patients and Methods: One hundred patients with DTC underwent near-total thyroidectomy and radioactive remnant ablation by iodine-131 (I131) with regular follow-up every 6 months during the first 2 years and at 6–12-month intervals thereafter by I131 whole-body scan (WBS), neck ultrasound, and sTg measurement in the hypothyroid state (TSH >30 mU/L). Patients were divided according to the imaging findings and sTg level into three groups: excellent response (ER) – no evidence of disease by imaging and sTg <1 ng/mL, indeterminate or acceptable response (AR) – nonspecific findings on imaging studies and sTg < 10 ng/mL, and incomplete response (IR) – patients with incomplete structural and/or incomplete biochemical response (sTg > 10 ng/mL). Results: The follow-up at 6-month postablation showed ER in 3 (3%) patients, AR in 29 (29%) patients, and IR in 68 (68%) patients. The second follow-up at 9–12-month postablation showed dramatic biochemical response with ER, indeterminate, and IR in 50 (50%), 34 (34%), and 16 (16%) patients, respectively, and 14 (14%) patient had structural recurrence. This change is highly statistically significant (P = 0.00). In the last follow-up (ranges from 3 to 10 years), 53 (55.8%) patients achieved ER, 42 (44.2%) AR and no patient with non complete response. The change in patients with IR between the second and the last follow-up is also statistically significant (P = 0.001). Conclusion: sTg measurement by the end of the 1st year is more reliable in the follow-up of patients with DTC and biochemical non complete response and considered significant predictor of disease-free status. Patients with biochemical IR still have the chance to achieve ER or AR by the passage of time without additional therapies. 

Papillary carcinoma thyroid metastases presenting as thyrotoxicosis post thyroidectomy

 A case report
Kanala Sai Krishnaja, Ramya Priya Rallapeta, Mehabunnisa Shaik, Ranadheer Manthri, Suresh Vaikkakara, TC Kalawat

Indian Journal of Nuclear Medicine 2019 34(2):134-136

Thyrotoxicosis can occur in the setting of differentiated thyroid cancer due to functioning metastases. Here, we report a case of a 63 year old woman with papillary carcinoma thyroid who underwent total thyroidectomy and defaulted for further scheduled treatment with high dose radioactive iodine therapy. 2 years after total thyroidectomy, she presented with signs and symptoms of thyrotoxicosis and a scalp swelling on the right side of frontal region. Excision biopsy revealed metastatic deposits of papillary carcinoma thyroid. Even after withdrawal of thyroxine, her serum thyrotropin did not rise and thyroglobulin levels were high, raising the suspicion of high volume tumour burden. I-131 whole body scan was done and it revealed radio iodine avid cervical lymph nodes along with functioning lung and skeletal metastases. 

Medicine

Hepatitis B: Knowledge and awareness among preclinical year medical students Mohan B Sannathimmappa, Vinod Nambiar, Rajeev Arvindakshan Avicenna Journal of Medicine 2019 9(2):43-47 Background and Objective: Hepatitis B is an occupational health hazard to health-care workers. The complete knowledge of hepatitis B virus (HBV) transmission and prevention is indispensable for medical students. This study was conducted to assess the knowledge and awareness of hepatitis B among preclinical year medical students.Materials and Methods: This is a descriptive cross-sectional study. A predesigned self-administered questionnaire concerning hepatitis B knowledge and awareness was distributed to all the preclinical year medical students. The data were collected, tabulated, and analyzed by Microsoft Excel and Statistical Package for the Social Sciences (SPSS) software, version 22. The results were expressed in numbers and percentages.Results: Of 251 students, only 132 students voluntarily participated in the study. Majority of the students (84.8%) were aware of HBV infection. Many students knew that blood transfusion (81.1%) and use of contaminated needles and syringes (74.2%) are major modes of transmission. However, less than 30% of the students had knowledge about other modes of transmission. More than 50% of the students lacked in their knowledge about clinical features and complications of hepatitis B infection. Majority of students (72.7%) were aware of HBV vaccination. However, many students did not know their vaccination status, whereas only 23.5% of the students were fully immunized.Conclusion: This study revealed lack of complete knowledge regarding hepatitis B among preclinical year medical students. They are at high risk of acquiring HBV infection during their clinical practice, later in life. Hence, implementation of well-structured education program in the first year itself is needed to create complete awareness among medical students about hepatitis B.

Left ventricular dyssynchrony assessment using tissue synchronization imaging in acute myocardial infarction Ahmed S Azazy, Mahmoud Soliman, Rehab Yaseen, Morad Mena, Haitham Sakr Avicenna Journal of Medicine 2019 9(2):48-54 Objectives: To assess left ventricular (LV) dyssynchrony in patients with ST elevation myocardial infarction (STEMI). Background: Mechanical synchronization disorder leads to a decrease in LV ejection fraction (LVEF) and stroke volume, an abnormal distribution of wall tension, and increase in workload during cardiac contraction. Methods: We enrolled 56 participants, 36 with acute STEMI and 20 healthy controls. The automatically color-coded time to peak myocardial velocity was measured using a 6mm sample volume, manually positioned within the two-dimensional-tissue strain image of the 12 basal and middle LV segments. Results: A significant delay was found between the septal-lateral and septal-posterior walls in patients with STEMI compared to patients in the control group (36.36 vs. −6.0ms, P = 0.036; and 42.7 vs. 23.94ms, P = 0.042, respectively). Furthermore, all segment maximum differences and all segment standard deviation (SD; dyssynchrony index) were found to be significantly higher in the STEMI group (131.28 vs. 95.45ms, P = 0.013; and 44.47 vs. 26.45ms, P = 0.001, respectively). A significant delay between the septal-lateral walls and septal-posterior walls, all segment maximum difference, and all segment SD (dyssynchrony index) were found in patients with complicated STEMI (70.89 vs. 15.83ms, P = 0.038; 57.44 vs. 19.06ms, P = 0.040; 138.11 vs. 100.0ms, P = 0.035; and 45.44 vs. 32.50ms, P = 0.021, respectively). There was a significant negative correlation between tissue synchronization imaging parameters and LVEF, and a positive correlation with LV end systolic dimension. Conclusion: Patients with acute STEMI showed significant LV dyssynchrony, which was an independent predictor of inhospital complications.

Comparative assessment of conventional chromosomal analysis and fluorescence in situ hybridization in the evaluation of suspected myelodysplastic syndromes: A single institution experience Denyo Adjoa Zakhia, Olga Voronel, Feras Zaiem, Kunil Raval, Jay Yang, Deborah Schloff, Anwar N Mohamed, Ali M Gabali Avicenna Journal of Medicine 2019 9(2):55-60 Background: Myelodysplastic syndromes (MDSs) are a heterogeneous group of clonal hematopoietic neoplasms, roughly half of which harbor cytogenetic abnormalities with diagnostic, prognostic, and therapeutic significance. Fluorescence in situ hybridization (FISH) for the most commonly seen abnormalities (5/5q, –7/7q, +8, and –20/20q–) is routinely performed alongside conventional cytogenetics (CC) in the evaluation of suspected MDS despite conflicting reports of its relative contribution compared to CC alone.Objectives: To assess the additional diagnostic and prognostic value of performing concurrent FISH versus CC alone in cases of suspected MDS.Materials and Methods: A total of 127 bone marrow samples submitted to our cytogenetic laboratory with a presumptive diagnosis of MDS were evaluated by concurrent CC and an MDS FISH panel.Results: CC was used as the gold standard method with 100% sensitivity in detecting suspected MDS-associated cytogenetic abnormalities. FISH alone had a sensitivity of 76%, whereas CC alone achieved a sensitivity of 97%. The addition of FISH did not change the diagnosis nor change the Revised International Prognostic Scoring System score in any patient. Moreover, in 12 cases identified as positive by both CC and FISH, CC identified multiple chromosomal aberrations of clinical significance not interrogated by the FISH probe panel.Conclusion: CC alone is sufficiently sensitive in detecting suspected MDS-associated cytogenetic abnormalities that influence clinical decision-making. Routine FISH testing does not provide a significant increase in test sensitivity when an adequate karyotype is obtained. Therefore, FISH testing is best reserved for suspected MDS cases lacking sufficient metaphases.

Child and adolescent health in northwestern Syria: Findings from Healthy-Syria 2017 study Abdullah Sulieman Terkawi, Basil Bakri, Amena S Alsadek, Abdulmuhsen H Al-Hasan, Mohamad S Alrahhal, Farhan M Alsaleh, Fadia A Alsatouf, Musa`ab I Arab, Hussam Jnaid, Adnan A Hadid, Rayan S Terkawi, Manal M Zahran, Nabiha A Alghannam, Khalid A Altirkawi Avicenna Journal of Medicine 2019 9(2):61-74 Objectives: Since the uprising in 2011, there has been limited health-care data from inside Syria in the academic literature. This study aims to provide an updated account of pediatric health needs in the northwestern part of Syria; this should help inform the management and delivery of health-care services in this population.Methods: This is a prospective study, using a data registry, of all pediatric patients seen in a single center in northwestern Syria, between February and December 2017. We used international classification of diseases (ICD-10) codes to define cases, and tested several covariates, including age, sex, season of the year, and conditions of living for possible correlations with major illness categories.Results: We included 11,819 patients, of whom 5,288 (45%) were male and 6,531 (55%) were female. Collectively, these patients had 23,427 encounters. Respiratory diseases were the most encountered illnesses among all age groups (6320 [27%]), except late teen females, among whom gynecological/obstetric complaints dominated. Infectious diseases caused the greatest disease burden across all age groups, with upper respiratory tract infections (URTIs), infectious diarrhea, and otitis media representing almost half (47%) of all cases in this category. Nutritional deficiencies were diagnosed in 978 patients (8%), mostly in infants and toddlers (92%). We identified 1192 (17%) cases of acute diarrhea among all age groups, making it the second most common condition after URTIs. As compared to town residents, patients living in camps for internally displaced people accounted for more cases of infectious diarrhea (58%), chronic anemia (60%), and malnutrition (66%), especially severe acute malnutrition (76% of malnutrition cases). Vaccine-preventable illnesses represented a sizable category; we reported 69 cases of hepatitis A, 2 of poliomyelitis, 9 of pertussis, 37 of varicella, 11 of mumps, 8 of rubella, and 1 case of measles.Conclusion: We have identified urgent health-care issues in this population, including extreme malnutrition, high rates of infectious diseases, and high rates of teenage pregnancy. Also, we observed a relapse of some vaccine-preventable illnesses, such as mumps and rubella, which are likely associated with the decline in vaccination rates.

Epidural analgesia for percutaneous kyphoplasty in a patient with multiple medical comorbidities Waseem S Alfahel, Alia S Dabbous, Mark E Thompson Avicenna Journal of Medicine 2019 9(2):75-77 Kyphoplasty is a minimally invasive procedure intended to stabilize the fractured bone and restore bone height. It involves percutaneous introduction of an inflatable bone tamp into a fractured vertebral body, followed by injection of bone cement into the ballooned pocket. Anesthetic options typically considered for this procedure include intravenous sedation or general anesthesia. These patients are often elderly, frail, in significant pain, and may poorly tolerate sedation or general anesthesia in the prone position. Spinal anesthesia has been suggested as an alternative method. However, it has major limitations. We would like to report a case of a 79-year-old patient with multiple comorbidities, who presented for kyphoplasty, where epidural anesthesia was conducted and successfully provided adequate analgesia as well as optimal surgical conditions.

Rare morbidity of permanent quadriplegia caused by neurenteric cyst of the cervical cord Henry Tan Chor Lip, Tan Jih Huei, Ariz Chong Abdullah, Noor Azman Bin A Rahman Avicenna Journal of Medicine 2019 9(2):78-81 The incidence of neurenteric cyst (NC) is rare, accounting for 0.3%–1.3% of all spine tumors. The occurrence of quadriplegia caused by NC is even scarcer. Herein we report on a young girl with a rare NC over the C2-C5 spinal cord, which led to the morbidity of permanent quadriplegia despite early surgical intervention. This case highlights the rare morbidity of cervical cord NC presenting with permanent quadriplegia that failed to respond despite early surgical excision.

Ileal volvulus secondary to cystic lymphangioma: A rare case report with a literature review Shoog F Alfadhel, Abdulmajeed A Alghamdi, Saif A Alzahrani Avicenna Journal of Medicine 2019 9(2):82-85 Lymphangioma is a benign malformation of the lymphatic system. It usually affects the neck, head, and rarely, the abdomen. Volvulus is a serious condition, which occurs as a result of bowel twisting around itself or around the mesentery leading to severe consequences such as obstruction. The most common cause of volvulus in children is malrotation. We report a rare case of a 2-year-old boy who was brought by his parents to the emergency room with the complaint of constipation for 5 days and vomiting for the last 4 days. Examination and plain abdominal X-ray suggested intestinal obstruction. Furthermore, ultrasonography indicated the presence of a cyst and dilatation of the bowel. On exploratory laparotomy, an ileal volvulus caused by cystic lymphangioma developed on the mesenteric wall and associated with ileal and jejunal dilatation was observed. The diseased segments were resected in addition to 5cm before and after the cystic lymphangioma to prevent recurrence.

Transcatheter closure of patent foramen ovale: an updated meta-analysis of randomized controlled trials Fahed Darmoch, Yasser Al-khadra, Homam Moussa Pacha, Mohamad Soud, M Chadi Alraies Avicenna Journal of Medicine 2019 9(2):86-88

Clinical and Scientific Research

The global D-Lemma: The vitamin D deficiency pandemic even in sun-drenched countries Michael F Holick Journal of Clinical and Scientific Research 2018 7(3):101-105

Does clinical posting in psychiatry change attitude towards psychiatry? A prospective study Animesh Sharma, GK Vankar, PB Behere, KK Mishra Journal of Clinical and Scientific Research 2018 7(3):106-113 Background: Worldwide, mental illnesses are on rise. There is an acute shortage of psychiatrists. Young medical graduates find psychiatry specialty a less attractive career option. The present study was conducted to find out attitudinal change of medical graduates to psychiatry specialty after their clinical posting. Methods: The study was carried out in a tertiary medical care centre situated in eastern Maharashtra in a rural setting. The medical graduates undergo rotation which includes clinical posting in psychiatry while they are in second year. One hundred medical students were administered Attitudes Towards Psychiatry-30 (ATP-30) questionnaire at the beginning and the end of two weeks of posting. Results: The response rate was 93% and the mean pre-rotation score on ATP-30 questionnaire was not significantly different as compared with the mean post-rotation score [107 ± 11.7 (SD) vs. 106 ± 12.4 (SD); (p=NS)]. Subgroup analysis revealed a significant decline [56 ± 6.4 vs. 54 ± 6.6 (p< 0.05)] in attitude on 15 positive questions of the questionnaire. Students with urban background [(55.8 ±6.6 vs 58.6 ± 9.3 (p=0.88)] as compared with rural background [58.1 ± 3.2 vs 53.9 ± 6.1 (p=0.03)] had significantly more decline on ATP-30 questionnaire. Conclusions: Overall, there was no change in medical students' attitude following two weeks clinical posting. Based on these findings medical curriculum including duration and frequency of clinical posting in psychiatry during undergraduate training requires change.

Three-dimensional conformal radiotherapy versus intensity-modulated radiotherapy in carcinoma cervix Revathi Badiginchala, Swapna Jilla, BV Subramanian, Prana Bandhu Das, Archana Prathipati, G Sanjeeva Kumar Journal of Clinical and Scientific Research 2018 7(3):114-118 Background: Cervical cancer is the most common gynecological cancer among Indian women. 3D-CRT treatment is associated with more acute and late toxicities, because of close proximity of bladder and rectum to the cervix. The newer technique like IMRT is associated with less toxicities. Our study is to compare 3D-CRT and IMRT in terms of dosimetric parameters, toxicities and clinical outcomes. Methods: From February 2015 to July 2016 total 40 newly diagnosed locally advanced cervical carcinoma patients were treated with concurrent chemo radiotherapy with weekly cisplatin. Those patients were randomized to arm A - 3D-CRT and arm B - IMRT. Results: The dosimetric parameters of the bladder, rectum, bowel bag, and pelvic bone marrow were significantly decreased in the IMRT arm as compared to 3DCRT arm except for V30, V50 of bowel bag and V50 of pelvic bone marrow. The acute and late toxicities were similar among both arms. All the patients were assessed for treatment response at 6 weeks after completion of the treatment. All achieved complete clinical response. Out of 40 patients only one had brain metastasis after a median follow up of 18 months. Conclusions: Though IMRT showed dosimetric reduction compared to 3D-CRT but it did not showed any clinical benefit. At present scenario in developing countries like India where the cancer centers are over loaded with the carcinoma cervix cases can be treated with the 3D-CRT technique without compromising clinical outcomes.

Anthropometric correlates of dyslipidaemia in various stages of chronic obstructive pulmonary disease G. Leela Jaya Madhuri, M Sriharibabu, Somanath Das, Y Himabindu, D Kiranmai, RK Chaitanya Reddy Journal of Clinical and Scientific Research 2018 7(3):119-123 Background: Chronic Obstructive Pulmonary Disease (COPD) is one of the major non-communicable diseases associated with increased morbidity and mortality. Even though COPD is a systemic disorder with the predominant involvement of lungs, several co-morbidities have been recognised in COPD. Both cachexia and obesity are common in COPD. This study explored the correlations between anthropometry and lipid parameters in different stages of COPD. Methods: This cross-sectional study conducted in a tertiary care teaching hospital included 120 subjects who satisfied the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for COPD. After thorough clinical examination according to a predesigned study questionnaire all subjects underwent spirometric assessment for determination of the stage of COPD. Anthropometric measures like BMI, waist circumference, hip circumference and lipid parameters were measured in all study subjects. Pearson's correlation coefficients were calculated to see the correlation between anthropometry and lipid profile. Results: Dyslipidaemia was seen in all stages of COPD even though the pattern of dyslipidaemia varied from stage to stage. Significant positive correlations were observed between anthropometry and lipid parameters in stages III and IV COPD. Conclusions: The observations made in this study reveal that anthropometry correlates with dyslipidaemia in late stages of COPD.

Study of oxidant and anti-oxidant status in patients with chronic kidney disease A V. S S. N. Sridhar, P V. L N. Srinivasa Rao, Vishnubhotla Sivakumar, P Satish, P Shalini, MM Suchitra, Vinapamula S Kiranmayi Journal of Clinical and Scientific Research 2018 7(3):124-130 Background: Chronic kidney disease (CKD) is associated with oxidative stress (OS), which occurs even in early stages of CKD and was shown to further contribute to progression of renal dysfunction and increased cardiovascular risk in CKD patients. Majority of studies have evaluated OS in CKD patients using limited biomarkers. Present study aimed at comprehensive evaluation of oxidant and antioxidant status in CKD patients. Methods: 120 patients diagnosed with CKD who were classified into three groups of 40 each [group-1 (CKD stage1 and 2), group-2 (CKD stage3 and 4) and group-3 (CKD stage 5] based on eGFR and 30 healthy controls were recruited. Malondialdehyde (MDA), protein carbonyls (PC), ferric reducing ability of plasma (FRAP), protein thiols, superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase were measured in all subjects. FRAP was corrected for uric acid (FRAP_UA) and MDA/FRAP_UA ratio was calculated. Score for oxidative stress (SOS) was calculated using the oxidant antioxidant parameters studied. Results: MDA, PC, MDA/FRAP_UA, FRAP and SOS were higher whereas protein thiols, SOD, GPx and catalase were lower in CKD patients than controls. Further, MDA, PC and FRAP and SOS increased progressively and protein thiols, SOD and catalase decreased progressively with increasing renal dysfunction. MDA, PC, FRAP and SOS showed positive correlation with creatinine and negative correlation with eGFR, whereas protein thiols, SOD, and catalase showed positive association with eGFR and negative correlation with creatinine. Conclusions: CKD patients are prone for oxidant injury which increases progressively with worsening renal dysfunction and is associated with degree of renal impairment. Score for oxidative stress helps in comprehensive assessment of oxidative stress in CKD patients.

How to treat Vitamin D deficiency in sun-drenched India - guidelines CV Harinarayan Journal of Clinical and Scientific Research 2018 7(3):131-140 Vitamin D plays an important role in calcium and mineral metabolism. It is astonishing to find vitamin D deficiency in sun drenched country like India. This could probably due to modernisation of India-mechanization, urbanization, change in life style, dress code and revision of vitamin D adequacy range. India has the unique problem of twin nutrient deficiency- vitamin D and calcium. Low calcium in the diet coupled with vitamin D deficiency has adverse consequences in the skeletal health. Any vitamin D schedule to treat/supplement should be accompanied by adequate calcium in the diet/supplementation. There are many international guide lines for vitamin D supplementation. This review aims at highlighting the vitamin D supplementation schedule suitable in Indian context keeping in mind the cost and compliance. Studies in south India using in vitro ampoule mode with 7-dehyrocholestrol has shown adequate formation of active form of vitamin D from mid-day sun. Time of the day, latitude, and increased skin pigmentation all influence the cutaneous production of vitamin D. Exposing 12%-18% of body surface area to unprotected sunlight for 30-45 mins is equivalent to taking 600-1000 IU of vitamin D which is the dose recommended by experts for fortification of food. Vitamin D synthesized in the skin last twice as long. We as human can get Vitamin D from abundant sunshine. There are various food fortification schedules suggested. The major source of vitamin D for both children and adults is unprotected sun exposure. In the absence of sun exposure adequate amount of vitamin D from dietary sources and supplementation is a must to satisfy body's requirement. In India, adequate amount of vitamin D should be accompanied by dietary/supplemental calcium to achieve desired skeletal benefits.

Pseudopseudohypoparathyroidism: an unusual case Srinivasa P Munigoti Journal of Clinical and Scientific Research 2018 7(3):141-144 We report unusual case of a 22-year-old male patient who presented with phenotypic features of Albright's hereditary osteodystrophy, but had associated multiple hormonal deficiencies suggestive of pseudo-pseudohypararthyroidism.

Left-sided chylothorax due to tuberculosis in an adult K Gowrinath, KR R. Umamahesh Journal of Clinical and Scientific Research 2018 7(3):145-148 A spontaneous chylothorax is rare. Chylothorax as a manifestation of tuberculosis (TB) is very rare even in countries where TB is endemic. We report a case of left sided chylothorax due to TB in a 50-year-old male alcoholic who presented with hypotension and hyponatremia. TB was diagnosed through histopathological examination of mediastinal lymph node biopsy. Initial conservative treatment with four days of tube thoracostomy drainage was effective but chylothorax recurred one week later after starting anti-TB drugs. Resolution of chylothorax was achieved with repeat tube thoracostomy drainage for four weeks and daily anti-TB therapy with isoniazid, ethambutol, rifampicin and pyrazinamide for two months followed by daily isoniazid and rifampicin for four months. Patient recovered well and chylothorax did not recur during the follow up period of three months.

Pulmonary atelectasis due to organised blood clot J Harikrishna, V Pradeep, G Mounika, S Lavanya, K Hemsai, C Sunil Kumar, B Vijayalakshmi Devi Journal of Clinical and Scientific Research 2018 7(3):149-150

An unusual case of sphenoid wing meningioma and adenocarcinoma of the caecum Mahmood Dhahir Al-Mendalawi Journal of Clinical and Scientific Research 2018 7(3):151-151