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   Table of Contents - Current issue
July-September 2018
Volume 15 | Issue 3
Page Nos. 121-179

Online since Monday, September 10, 2018

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Editorial p. 121
RN Srivastava
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Extranodal tuberculosis of the head and neck p. 122
Santosh Kumar Swain, Mahesh Chandra Sahu, Manash Ranjan Baisakh, Anwesha Banerjee
Extranodal tuberculosis (TB) of the head-and-neck area is a rare clinical entity and constitutes the less common type of extrapulmonary TB. It often creates challenges among head-and-neck physicians for its diagnosis and treatment. Extranodal TB is a rare clinical entity and has no specific clinical features. It is often a differential diagnosis of head-and-neck malignancies, chronic infective or noninfective ulcers. Early diagnosis and its treatment may avoid complications and needless major surgery. The purpose of this review article is to discuss the epidemiology, pathophysiology, clinical presentations, diagnostic challenges, and treatment of the extranodal TB of the head-and-neck area.
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Nasal myiasis in clinical practice p. 128
Santosh Kumar Swain, Mahesh Chandra Sahu, Manash Ranjan Baisakh,
Nasal myiasis is an opportunistic parasitic infestation of human as well as animals. Infestation of the nasal cavity by dipterous larvae is called nasal myiasis which is commonly seen in developing countries where health and sanitation are poor. Different predisposing factors associated with nasal myiasis are atrophic rhinitis, diabetes with purulent nasal discharge, midline granulomatous lesions or malignancy, and poorly nourished patients with poor hygiene. Other possible predisposing factors causing nasal myiasis include neglected children, mental retardation, and elderly age. Nasal endoscopy is a better method for removal of maggots under direct vision. Nasal endoscopic method is a better technique for the removal of maggots than conventional manual method. The maggots which are often located in deep and inaccessible areas are easily identified and removed.
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Novel drug - dinutuximab for high-risk neuroblastoma p. 132
Supriya Kushwah, Ashutosh Kumar, S Shabnam
Neuroblastoma is the most common extracranial tumor in children aged <5 years. Prognosis of high-risk neuroblastoma is not good even after use of aggressive chemotherapy. Newer drug anti-GD2 monoclonal antibodies, dinutuximab in combination with granulocyte-macrophage colony-stimulating factor or interleukin-2, have been recently approved by Food and Drug Administration for the treatment of high-risk neuroblastoma. Dinutuximab binds to the glycolipid GD2 present on neuroblastoma cells and cells of neuroectodermal origin and enhances cell lysis through antibody-dependent cell-mediated cytotoxicity and complement-dependent cytotoxicity.
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Management of neglected clubfoot by ilizarov device, without osteotomy: Yemen experience Highly accessed article p. 135
Sharker Barker
The medium-term clinical and functional results of treating neglected clubfoot deformities with Ilizarov device are good. In a limited health-care resource country (such as Yemen) and poor financial situation and education of the patients, the results of Ilizarov surgical correction of the neglected and severe deformities of the foot and ankle are promising, and it seems an excellent surgical option for this challenging condition.
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Prevalence of opportunistic enteric parasitic infections in hiv infected individuals and their correlation with cd4 count p. 138
Anita Kumari Gupta, Satyaprakash Jindal, GK Adithya,
Background and Objectives: Intestinal opportunistic infections have been recognized as common complications of HIV infection. The aim of this study was to identify and determine the prevalence of opportunistic enteric parasites affecting the HIV-infected patients and to correlate the presence of these parasites with CD4+ T-cell counts. Materials and Methods: Fecal samples were collected from 100 HIV-seropositive individuals with diarrhea and examined for enteric parasites by direct microscopy. A blood samples were taken for CD4 counts simultaneously. The prevalence of various enteric parasites in patients with CD4 count <200 cells/μl, 200–500 cells/μl, and >500 cells/μl in HIV-infected patients was compared. Results: Enteric parasites were detected in 62% of patients with diarrhea in HIV-seropositive individuals. Among them, Cryptosporidium parvum (48.3%) was the most common parasite followed by Isospora belli (16.1%). The prevalence of enteric parasites was significantly higher (P < 0.01) in patients with chronic diarrhea (88.2%) compared to acute diarrhea (48.4%). There was a significant difference (P < 0.01) in opportunistic enteric parasitic infection rate in patients with CD4 counts <200 cells/μl and >200 cells/μl (81.48% vs. 39.1%). Conclusion: Opportunistic enteric parasitic infections are very common in HIV-infected individuals with chronic diarrhea and low CD4 counts. It can be recommended to stool examination in this group of patients, which may help in early treatment and prevention of morbidity.
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Distal femoral fractures fixed by distal femoral locking compression plate: Functional outcomes and complications p. 142
KC Kapil Mani, Raju Vaishya, RC Dirgha Raj
Background: Fractures of distal femur are complex type of injuries that are difficult to manage and produce long-term disability if not treated appropriately. Anatomical reduction of articular fracture fragments, restoration of limb length, and early mobilization exercises are key factors for optimal outcomes of involved limb after surgical treatment. Distal femoral locking compression plate (DFLCP) is a relatively newly designed implant in which screws are locked into the plate to create fixed angle construct. Materials and Methods: This was a prospective analytical study of 40 patients with distal femoral fractures fixed by DFLCP. Demographic profiles, time to unite the fractures, functional outcomes as well as complications related to this surgery were noted. Results: Time to unite the fracture was 19.32 ± 5.48 weeks (range 14–32 weeks). There were one case of nonunion, one case of malunion (varus union <10°), four case of delayed union, two cases of superficial infection, one case of deep infections, one case of implant failure, and two cases of extensor lag of more than 15°. Based on Neer's scores, there were 30% excellent, 45% satisfactory, 20% unsatisfactory, and 5% failure rates. Conclusion: Distal femoral locking plate is the treatment of choice in the management of comminuted distal femoral fractures both in Type A and Type C varieties. It not only maintains the biological environment of bone but also prevents metaphyseal collapse and provides the stable construct for fracture union with good functional outcomes.
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In vitro testing using immunocap provides reliable assessment of sensitizing patterns to local allergens in patients with rhinitis/asthma p. 147
Sujoy Khan
Background: Bronchial asthma affects over 300 million people worldwide and half of these patients have underlying allergic disease. Accurate identification of allergen triggers will help identify patients that may benefit from immunotherapy. Objective: The objective of this study was to understand whether in vitro testing provides accurate identification of suspected local allergens in our patients. Methods: A retrospective study was conducted on patients between 2015 and 2016 with persistent mild/moderate-severe rhinitis/asthma referred for aeroallergen sensitization tests. Total immunoglobulin E (IgE) and allergen-specific IgE levels were done using Phadia 100 (Thermo Fisher Scientific). Descriptive statistics were done using Microsoft Excel and nonparametric statistics using MedCalc software V18. Results: A total of 106 patient records (including 30 children) were analyzed. The median total IgE during 2015 (n = 38) was 402 kU/L (interquartile range [IQR] 25–75, 102–871 kU/L), while for 2016 (n = 68) was 509 kU/L (IQR 25–75, 131–1245 kU/L) (standard deviation comparison nonsignificant, P = 0.536). Thirty of 106 patients (28.3%) had no aeroallergen sensitizations. Allergen-specific IgE levels revealed that the highest sensitization rate was to house dust mites (both Dermatophagoides pteronyssinus and Dermatophagoides farinae), followed by cockroach and ragweed pollen (homologous to Parthenium hysterophorus). Median IgE level among 30 children was 511 kU/L (IQR 25–75 51.8–1688 kU/L). Almost 60% children were sensitized to house dust mites. Twelve of 30 children (40%) were polysensitized (i.e., specific IgE >0.35 kUA/L to ≥4 allergens) with 30% sensitized to P. hysterophorus. Mold sensitivity was 10% in both the years studied. Conclusions: ImmunoCAP method provides reliable assessment of sensitizations even for local allergens. House dust mite, cockroach, and Parthenium allergens appear to be important predictors of asthma morbidity not only among adults but also among children in Eastern India. Immunotherapy with house dust mites may prove beneficial in selected patients.
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Civilian nonmissile penetrating brain injury p. 152
Shameem Ahmed, Deep Dutta
Background: Civilian nonmissile penetrating brain injuries (CNPBIs) have specific characteristic features that are different from missile injuries. Our study presents our experiences on the characteristic features as well as management of such patients. Materials and Methods: We have retrospectively reviewed 11 consecutive patients with CNPBI, having only anterior skull base injury, managed in our institute during 4-year period. The mechanism of injury, clinical investigations, and complications were analyzed with more emphasis on diagnostic and treatment regimen. Results: The 11 cases included in our study comprised 10 males and 1 female. Majority (72.7%) of the patients were adults with a mean age of 27.5 years. The mechanisms of injury often include accidental fall, either onto a small-diameter sharp object (5 cases) or while carrying such an object in hand (2 cases). Other mechanisms were stabbing and accidental. Clinical manifestations included periorbital hematoma (10 cases, 45.5%) and cerebrospinal fluid rhinorrhea or orbitorrhea (4 cases, 18.2%) as well as signs of embedded foreign object (8 cases, 36.4%). We performed emergency craniotomy in 10 cases and skin debridement in 1 case. Postoperative complications were abscess (1 case), seizure (1 case), and traumatic carotid-cavernous fistula (1 case). Conclusion: Nonmissile civilian injuries are generally on the rise and therefore deserve more attention. We observed that clinical outcomes were excellent in 7 (Glasgow Outcome Scale (GOS) of 5) and good in the remaining 4 (GOS of 4) during 6 months–4 years (mean: 2.3 years) follow-up.
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Celiac axis stenosis in a patient undergoing pancreatoduodenectomy p. 158
GK Adithya, Satya Prakash Jindal, Varun Madaan, Chitra Singh, Sandeep Vohra, Vivek Tandon, Deepak Govil
Celiac axis (CA) stenosis is a commonly detected condition in candidates planned for upper abdominal surgery. In major abdominal surgeries, CA stenosis has its own importance. In our case, a 57-year-old female was admitted with obstructive jaundice and diagnosed to have distal cholangiocarcinoma and was planned for surgery. Computed tomography scan (done from outside centre) was discussed with our radiologist; a moderate-to-severe CA stenosis was noted with collaterals being developed between superior mesenteric and gastroduodenal arteries. Based on this, she was planned for preoperative biliary and vascular stenting before definitive surgery. Whipple procedure was done after stenting of the CA stenosis. Intraoperatively, we found a wide and good caliber hepatic artery being fed by the CA itself. Postoperatively, there was no complication related to ischemia or anastomotic leak. This case is being reported to emphasize the importance of thorough radiological evaluation before taking up any major abdominal surgery.
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Wandering spleen with pancreatic volvulus and associated scimitar syndrome: A rare anomaly detected on computed tomography p. 161
Ravi Kumar Varma Kalidindi, Srinivas Metta, Tripura Mandava, Sesha Mohan Debta
Pancreatic volvulus with wandering spleen and associated scimitar syndrome and sequestrated lung of the right lower lobe is a rare congenital anomaly. Wandering spleen is a rare clinical condition which occurs due to the laxity and absence of normal intraperitoneal ligaments that hold the spleen in its place. Wandering spleen with pancreatic volvulus and associated scimitar syndrome has never been described in the literature to the best of our knowledge. We present the computed tomography of a young female patient who presented with acute pain abdomen.
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Treatment of endometreiosis: Changing trends in management p. 166
U Nagashree, Sumana Manohar, R Charumathi
Endometriosis is one of the most common gynecological disease affecting 6-10% of women of reproductive age. There is no cure for endometriosis-except a few methods of reducing the symptoms; both medical and surgical. Prolonged medical treatments to suppress the symptoms alone is not beneficial. The transformation of endometriosis to malignancy is always a possibility and the need for proper follow up and complete surgical clearance should be explained to the patient.
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Rare case of acute abdomen: Right colon perforation due to the colon diverticulitis p. 169
Faruk Pehlivanli, Gökhan Karaca, Oktay Aydin, Sevilay Vural, Figen Coskun
Colonic diverticula and related complications are common pathologies in elderly patients. In older patients, colonic diverticulum perforation is more common in the sigmoid colon, whereas right colon diverticulum perforation is rather rare. In younger patients, especially in patients under 30 years of age, right colon diverticula are more common than left colonic diverticula. Therefore, right colon diverticulum perforation should be considered in patients with acute abdomen in this age group. In this case, right column diverticulum perforation is presented in a patient with acute abdomen findings.
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A rare case of isolated retro-orbital fungal granuloma p. 172
Ramiya Ramachran Kaipuzha, Davis Thomas Pulimoottil, Satvinder Singh Bakshi, Suriyanarayanan Gopalakrishnan
We report here the first case of retro-orbital fungal granuloma caused by Aspergillus versicolor. A 52-year-old male presented with protrusion of left eye associated with pain in the left eye and watering of the left eye for 6 months duration. Left eye examination showed axial proptosis, and fundus examination revealed blurring of the nasal disc margin. Diagnostic nasal endoscopy revealed an irregular pinkish proliferative mass medial to the middle turbinate. Plain computed tomography of the orbits showed a retrobulbar intraconal lesion in the left orbit. The patient was taken up for endoscopic orbital and optic nerve decompression with debulking or retro-orbital mass under general anesthesia. Culture on Sabouraud's dextrose agar grew Aspergillus species. The patient was started on oral itraconazole 100 mg twice daily, and over the course of 2 months, the left eye proptosis reduced significantly. Review at 2 years postoperatively did not reveal any recurrence of symptoms. Endoscopic clearance of the disease combined with oral antifungals is the appropriate modality of therapy for aspergillosis.
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Klatskin tumor (hilar cholangiocarcinoma) p. 175
Reddy Ravikanth, Denver Steven Pinto
Klatskin tumor is a term that was given to a hilar cholangiocarcinoma, occurring at the bifurcation of the common hepatic duct. Typically, these tumors are small, poorly differentiated, exhibit aggressive biologic behavior, and tend to obstruct the intrahepatic bile ducts. Here, we present the multidetector computed tomography findings in a case of hilar cholangiocarcinoma.
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Mucoepidermoid carcinoma of the vermillion border of the upper lip: A rare occurrence p. 177
Renuka Masodkar, Ganesh Jadhav, Sapna Verma
Mucoepidermoid carcinoma (MEC) is a rare tumor. Very few cases of MEC of the upper lip have been reported in the literature. We report a case of 34-year-old female with MEC of the upper lip treated with surgery and postoperative radiotherapy.
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