Neurotoxoplasmosis is a major cause of morbidity and mortality, especially in immunocompromised patients. Definitive diagnosis is invasive and difficult thereby requiring a therapeutic trial. We herein report a case of an 11-year-old boy who presented with a tuberculoma on computerized tomography (CT) brain and did not show any clinical improvement on anti-tuberculous drugs. Subsequently, reviewing the CT scans and with supportive serology, a diagnosis of neurotoxoplasmosis was considered. A trial of antitoxoplasmosis therapy was given to which the child fully responded in two weeks. Three weeks later, his magnetic resonance imaging showed complete resolution of the lesion. This report provides an insight into the significance of therapeutic trial in neurotoxoplasmosis.

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Background: Outcome following Acute Disseminated Encephalomyelitis (ADEM) is variable and there are only limited studies from India. Aim: The study aims to evaluate the predictors of functional outcome in a cohort of patients with ADEM. Setting: Tertiary-care teaching hospital. Materials and Methods: Patients admitted with the diagnosis of ADEM from 1999 to 2004 have been included. Clinical features and radiological findings were evaluated. Functional outcome at discharge was scored using modified Rankin Scale and patients were followed up regularly. Statistical Analysis: Chi-Square test or Fisher's exact test, and Student's t test for comparison of categorical and continuous variables, respectively, and logistic regression for multivariate analysis. Results: Sixty-one patients were evaluated (mean age 22±15.9 years, 1-65). Fifty-two patients had preceding febrile illness or vaccination with mean 9.1±12.5 days interval to first neurological symptom. Non-specific febrile illnesses were the commonest trigger. Commonest findings were motor signs (n=41), impaired consciousness (n=33), bladder symptoms (n=21), ataxia (n=15), and seizures (n=14). Between adult (mean age 30.1±13.1 years, 13-65, n=38), and pediatric (mean age 6.2±2.8 years, 1-12, n=23) patients, language disturbances were more common in the latter (P=0.047). MR imaging (n=35) demonstrated lesions mostly in frontoparietal white matter (n=23) and thalamus (n=15). Nine patients expired. Patients with poor functional outcome at discharge more often had impaired consciousness (P=0.038) and seizures (P=0.06). At follow-up (n=25), deficits included motor signs (n=15) and bladder symptoms (n=5). Conclusions: ADEM has a wide range of neurological presentations and language disturbances are more common in pediatric patients. The presence of impaired consciousness, and possibly seizures, predict poor functional outcome at hospital discharge.

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Background: The various risk factors for diabetic retinopathy and its spectrum are still poorly understood in the Indian population. Aims: To study the association of various systemic risk factors with retinal hard exudates in type 2 diabetic north Indian patients and to measure the incidence of dyslipidemia in them. Settings and Design: A tertiary-hospital-based cross-sectional study. Materials and Methods: An observational case-study which included 180 type 2 diabetic patients (180 eyes) of nonproliferative diabetic retinopathy (NPDR) with clinically significant macular edema (CSME). In these patients the retinal hard exudates were graded on a central 500 fundus picture using modified Airlie House classification and divided into three groups of absent or minimal hard exudates (Group 1), hard exudates present (Group 2) and prominent hard exudates (Group 3). Their association with various risk factors, namely the age of onset of diabetes and its duration, gender, insulin therapy, and various systemic parameters like hypertension, blood hemoglobin, glycosylated hemoglobin, serum (s.) creatinine levels, 24-h proteinuria and complete lipid profile including total s. cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), very low-density lipoprotein cholesterol (VLDL) and s. triglyceride (TG) was studied. The incidence of dyslipidemia was also calculated among these groups of patients. Statistical Analysis: ANOVA test, linear regression analysis and Spearman's correlation test. Results: On univariate analysis, the retinal hard exudates were significantly associated with s. creatinine (P=0.016), systolic blood pressure (P=0.014), s. cholesterol (P<0.001), s. LDL (P=0.008) and s. TG (P=0.013) levels. While on linear regression analysis, s. cholesterol (P<0.001) and s. LDL cholesterol (P=0.028) were found to be independent risk factors affecting the density of retinal hard exudates. On Spearman's correlation test, the retinal hard exudates showed a significant positive correlation with systolic blood pressure (P=0.019), s. cholesterol (P<0.001), LDL (P=0.002) and TG (P=0.014) levels. The incidence of dyslipidemia varied from as high as nearly 70% among patients of Group 3 compared to as low as 18% among Group 1 patients. Conclusion: Serum cholesterol and LDL are independent risk factors for retinal hard exudates in type 2 diabetic north Indian patients who suffer from a remarkably high incidence of dyslipidemia.

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Context: The usefulness of the acute octreotide test in the selection of patients with acromegaly for chronic somatostatin depot analogues treatment is controversial. Aims: To determine the efficacy of acute octreotide suppression test (OST) in predicting response to long-term somatostatin analogue (Octreotide-long-acting repeatable, OCT-LAR) therapy in patients with acromegaly. Settings and Design: Prospective study (2006-2007) conducted at a tertiary healthcare centre in western India. Materials and Methods: Sixteen drug-naive patients with active acromegaly (postoperative±post radiotherapy) underwent 50 µg subcutaneous OST. Ten patients were treated with OCT-LAR for one year. Remission was defined as a nadir growth hormone (GH) <1 ng/ml during 75 g oral glucose tolerance test (OGTT) (0, 10, 30, 60, 120, 180 min) and normal age, sex-matched insulin-like growth factor 1 (IGF1) levels. Statistical Analysis: SPSS Software Version 11 was used for data analysis. Results: Using GH cutoff <1 ng/ml, four patients (40%) achieved control at 12 months, while five patients (50%) achieved normal IGF1 values. The mean basal GH levels in 10 responsive, four controlled and six uncontrolled patients were 34.7±61.14, 4.5±1.3 and 54.8±74.2 ng/ml respectively which suppressed to mean nadir GH of 3.75±4.03, 0.66±0.15 and 5.8±4 ng/ml respectively. Sensitivity, specificity, negative and positive predictive value for nadir GH <1 ng/ml reached after an OST was 100% each in predicting remission in our cohort. Odds for control increased if the baseline GH was low (<5 ng/ml in our cases). Conclusions: Nadir GH <1 ng/ml following an OST is a useful predictive marker of achieving disease remission with long-term OCT-LAR therapy.

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A 70 year-old diabetic man receiving anti-coagulant therapy (Warfarin) for pulmonary embolism secondary to factor V Leiden deficiency, presented to the hospital for chest pain. After initial evaluation, he was started on aspirin (300 mg) and clopidogrel (300 mg). Three days after he was discharged, he presented with preseptal cellulitis complicating left upper eyelid chalazion. Initially, he was treated with several anti-microbial agents used sequentially. Although, the cellulitis resolved, he developed total hyphema of the left eye. The complication seems to have resulted from a complex interaction amongst anti-microbial agents, Warfarin and anti-platelet agents.

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Background: The pathogenesis of preeclampsia is poorly understood and recent evidence suggests that the incidence varies depending upon the season. Aim: This study was carried out to determine whether there is a seasonal variation in the presentation of preeclamptics undergoing cesarean delivery in a tropical rainforest belt. Setting: A university teaching hospital. Study Design: Retrospective. Materials and Methods: The hospital records of consecutive patients (July 1996-June 2006) with preeclampsia, who underwent cesarean delivery in a tertiary care centre, were reviewed. Data collected included patient demographics, total number of deliveries, number of cesarean deliveries, and number of preeclampsia patients and time of presentation for cesarean section. Approval of the local ethical committee was obtained. Statistical Analysis: The EPI info software program was used for statistical analysis. Results: A total of 6798 deliveries were recorded during the study period resulting in 6485 live births. There were 1579 cesarean deliveries during the period. Of these, 196 patients had toxemia of pregnancy (166 with preeclampsia and 30 with eclampsia). One hundred and forty-one patients (9% of cesarean deliveries) had cesarean delivery during the rainy season and 55 (3.5%) during the dry season (P<0.05). Amongst preeclampsia patients, 115 presented (7%) during the rainy season and 51 (3.2%) during the dry season (P<0.05). In the eclampsia group, 26 (1.65% of cesarean sections) presented during the rainy season and four (0.25%) during the dry season (P<0.05). Conclusions: There was a seasonal variation in the cesarean delivery required for preeclampsia/eclampsia patients. This may help in counseling women on when to plan their pregnancy in order to reduce the morbidity and mortality associated with this apparent seasonal disease.

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Voriconazole, a triazole antifungal, is gaining popularity in the treatment of invasive fungal infections, mostly in the immuno-compromised patients. Voriconazole, a CYP2C9 inhibitor, has many potential drug interactions. Its interactions are both due to its pharmacokinetic properties and the genetic polymorphism of CYP2C9 enzymes. Here is a case report of one such drug-drug interaction between voriconazole and glimepiride, an oral hypoglycemic agent, which led to prolonged and persistent hypoglycemia for 48 h. It was diagnosed by the temporal association of the occurrence of symptoms with voriconazole intake. The patient stabilized on withdrawal of the responsible drugs. Due to the high incidence of co-prescribing voriconazole with other drugs, caution has to be exercised while prescribing it. Clinicians' awareness, a high index of suspicion and constant monitoring for adverse drug reactions, expected or unexpected drug interactions has to be emphasized, even if the co-prescribed drugs are in normal therapeutic doses.

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Cystic neoplasms of the kidney presenting in childhood always present a therapeutic dilemma. Low-risk renal tumors of childhood cover a wide spectrum: cystic nephroma, cystic partially differentiated nephroblastoma and cystic Wilms' tumor. There are difficulties in differentiating these tumors on preoperative imaging. The present case presented such a therapeutic dilemma and was finally diagnosed as a cystic variant of favorable-histology Wilms' tumor with osteolytic metastasis to the ribs. The case is presented in view of its rare presentation and the therapeutic and diagnostic challenges involved.

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Nephrectomy after pyonephrosis, repeated acute pyelonephritis or chronic pyelonephritis is a challenge for any surgeon, owing to adhesions around the kidney. We encountered an unusual case of post-nephrectomy urinary fistula, as a complication of subcapsular nephrectomy. This occurred as a result of residual renal tissue after nephrectomy, which was subsequently excised using methylene blue as an aid to ensure complete excision. Such a complication has never been reported in existing literature. We reviewed the literature for any such related complications to gather an insight to its occurrence and also present a simple point of technique to avoid such a catastrophe.

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A 25 year old woman received daily injection of 0.6 mg atropine for seven days by the intra-venous route. In addition to fever, incomprehensible speech and alteration of sensorium she developed albuminuria, hemoglobinuria and myoglobinuria. A diagnosis of atropine-induced rhabdomyolysis was made on the basis of clinical presentations and investigations. Although, datura poisoning and intoxication with wild mushrooms are known to result in rhabdomyolysis, this can be considered to be the first case of atropine-induced rhabdomyolysis and myoglobinuria.

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Background: Consultation of experts in the internal medicine or surgery subspecialties is needed in the hospitalized population according to decisions of the house staff. Sometimes the referrals are not justified, consuming time and money without a significant change in the patient outcome. Objectives: The aim of our retrospective study was to evaluate justification of consecutive referrals of hospitalized patients for gastroenterology consultation. Materials and Methods: Request for consultation was deemed not justified when at least one of the following parameters was found: No contribution to case management, discharge before consultation, cancellation at the last minute, and a recommendation for ambulatory management or surgery. Results: In August-September 2006, there were 232 requests for gastroenterology consultations. Of them 127 (54.7%) were men. The average age was 64.13±20.33 years. Ninety-four (40.2%) of the cases had been hospitalized because of other reasons than the consultation issue. Consultation was not justified in 60 patients (25.9%). Ambulatory management was a possibility in 151 cases (65.0%). Request for colonoscopy and gastrointestinal background disease were the only significant predictive factors for justification of consultation, P<0.0001 for both. Conclusions: In one fourth of the cases, gastroenterology consultation was not justified according to our strict criteria.

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