Management of Levofloxacin Induced Anaphylaxis and Acute Delirium in a Palliative Care Setting

Levofloxacin is a commonly prescribed antibiotic for managing chest and urinary tract infections in a palliative care setting. Incidence of Levofloxacin-associated anaphylaxis is rare and delirium secondary to Levofloxacin is a seldom occurrence with only few published case reports. It is an extremely rare occurrence to see this phenomenon in combination. Early identification and prompt intervention reduces both mortality and morbidity. A 17-year-old male with synovial sarcoma of right thigh with chest wall and lung metastasis and with no prior psychiatric morbidity presented to palliative medicine outpatient department with community-acquired pneumonia. He was initiated on intravenous (IV) Ceftriaxone and IV Levofloxacin. Post IV Levofloxacin patient developed anaphylaxis and acute delirium necessitating IV Hydrocortisone, IV Chlorpheneramine, Oxygen and IV Haloperidol. Early detection and prompt intervention helped in complete recovery. Patient was discharged to hospice for respite after 2 days of hospitalization and then discharged home. Acute palliative care approach facilitated management of two life-threatening medical complications in a palliative care setting improving both quality and length of life.     

Frequency of Helicobacter pylori and CagA Antibody in Patients with Gastric Neoplasms and Controls: The Indian Enigma

Background Despite association between H. pylori and gastric neoplasm (GN) from the developed world, studies from India, where infection is more common and acquired early, are scant and contradictory. Methods Two hundred and seventy-nine patients with GN from two northern and one eastern Indian centers during the period 1997–2005, 101 non-ulcer dyspepsia (NUD), and 355 healthy volunteers (HV) were evaluated for H. pylori [rapid urease test (RUT), histology and anti-H. pylori, and CagA IgG serology]. Results Patients with GN [263 gastric carcinoma and 16 (6%) primary gastric lymphoma, 208 male] were older than HV (n = 355, 188 male) and NUD (n = 101, 54 male) patients (53 ± 12 versus 44 ± 17 and 43 ± 13 years, respectively; P < 0.001). Eastern Indian patients with GN (n = 145) were younger than those from northern India (n = 134; 52 ± 12 versus 55 ± 12 years; P < 0.007, t-test). In GN and NUD patients H. pylori positivity by RUT [86/225 (38%) versus 46/101 (46%)], anti-H. pylori IgG [154/198 (78%) versus 85/101 (84%)], and histology [136/213 (64%) versus 55/101 (55%)] were comparable (χ ²-test). Serum IgG anti-H. pylori antibody was more common among HV than among GN patients [300/355 (85%) versus 154/198 (78%); P = 0.04, χ ²-test]. Intestinal metaplasia was more common in GN than in NUD patients [101/252 (40%) versus 2/98 (2%), P < 0.000, χ ²-test]. CagAIgG was more common in GN than in NUD patients [124/163 (76%) versus 64/101 (63%)] but comparable to that in HV patients [87/98 (89%), P = NS]. Conclusion Frequency of H. pylori as detected using endoscopy and serology-based tests is not higher among patients with GN as compared with controls in India.     

Long-term follow-up after pneumatic dilation for achalasia cardia: factors associated with treatment failure and recurrence

BACKGROUND: Though most patients with achalasia cardia (AC) respond to pneumatic dilation (PD), one-third experienced recurrence. Long-term follow-up studies on factors associated with various outcomes are scanty. METHODS: In this retrospective study, 126 patients (36.5 +/- 14.6 yr, 76 male) with AC (diagnosed by esophagoscopy, barium esophagogram, and/or manometry) were followed up in person or through mail. The median dysphagia-free duration was calculated by Kaplan-Meier analysis. Factors associated with nonresponse and recurrence after PD were determined using univariate and multivariate analyses. RESULTS: Symptoms were dysphagia (126, 100%), chest pain (21, 17%), regurgitation (61, 48%), weight loss (33, 26%), and pulmonary symptoms (23, 18%); 5 of 126 (4%) had megaesophagus (> or =7 cm). The mean lower esophageal sphincter (LES) pressure was 38.7 +/- 16.8 mmHg. One hundred and fifteen of 126 (91%) patients responded to PD (90 (71%) to first session); 25 of these had recurrence of dysphagia after 15 +/- 17 months. Post-PD chest pain requiring hospitalization occurred in 21 of 126 (17%; one had an esophageal perforation). Post-PD LES pressure, which was assessed in 48 of 126 patients, had decreased by >50% from baseline in 14 of 29 responders, 0 of 11 nonresponders (p= 0.004, chi(2) test), and 5 of 8 relapsers. The median dysphagia-free duration by Kaplan-Meier analysis was 60 months (SE 2.7, 95% CI 54.7-65.3). On univariate analysis, male gender, pulmonary symptoms (nocturnal coughing spell, history of respiratory infection), absence of chest pain, and failure to achieve a reduction in LES pressure >50% after PD were associated with poor outcome; whereas age, grade of dysphagia, regurgitation, megaesophagus, and LES pressure before PD were not. Male gender was associated with poor outcome by multivariate-analysis. CONCLUSIONS: PD is an effective and safe treatment for AC. Post-PD LES pressure measurement may be helpful in assessing response. Male patients have poorer outcomes following PD.     

Manometric and symptomatic spectrum of motor dysphagia in a tertiary referral center in northern India

Background  

We studied the spectrum of motor dysphagia in a northern Indian tertiary referral center.     

Presence and severity of COPD among patients attending cardiology OPD of a tertiary healthcare centre

Chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) are two very common entities, which often coexist due to common risk factors notably smoking. Though both are common causes of chronically poor health, only cardiovascular disease has got major health priority and government research funding. COPD is largely underdiagnosed and even unsuspected among cases of IHD. The present study wants to address this relatively unexplored area of magnitude of COPD among cases of IHD. A total of 86 (male-65, female-21) consecutive stable and ambulatory IHD patients diagnosed by cardiologist and fulfilling the criteria for inclusion, were selected from cardiology outpatient department of IPGME&R, Kolkata from January 2005 to August 2006. Associated COPD was found in 51.2% (n = 44) patients of the study group (males-36, females-8) according to GOLD criteria; 90.9% of cases of COPD had moderate to severe disease. This was much higher than the prevalence of COPD among general population. A positive correlation was found between severity of COPD and impaired left ventricular ejection fraction (EF). This study also shows that general perception about COPD is poor among patients and their physicians. Most of the COPD cases (81.8%) of IHD were newly detected in this study by spirometric evaluation. Use of inhaled bronchodilator among the previously diagnosed cases is also very low (15.9%). Awareness regarding coexistence of the two diseases may be helpful in management and reduction of mortality and morbidity of COPD in IHD.     

IL-1 receptor antagonist (IL-1Ra) gene polymorphism in patients with inflammatory bowel disease in India

Objective

An association between polymorphism in the gene coding for the anti-inflammatory cytokine interleukin-1-receptor antagonist (IL-1Ra) and ulcerative colitis (UC) has been reported. To date, there is no report from India confirming this association. In the present study the aim was to assess the allele frequencies and carriage rates of different alleles of 86 bp (base pair) variable number tandem repeat (VNTR) in intron 2 of the IL-1Ra gene in patients with inflammatory bowel disease (IBD) and healthy controls from northern India.

Material and methods

Eighty-two patients with UC, 21 with Crohn's disease (CD) and 141 ethnically matched controls were enrolled in this study. Genotyping was done using a polymerase chain reaction (PCR) amplification of the intron-2 fragment harboring a VNTR nucleotide sequence. The PCR products were separated on 2% agarose gel. Statistical analysis was performed using the chi-squared (χ²) test.

Results

The frequencies of allele 2 in UC, CD and healthy controls were 26%, 50% and 24%, respectively. The frequency of allele 2 in CD was higher than that in UC (p=0.002; OR?=?2.9) and healthy controls (p=0.001; OR?=?3.1; 95% CI?=?1.5--6.3). Alleles 3 and 4 were absent in patients with CD, while allele 5 was absent in all three groups.

Conclusions

The present study demonstrated an association between allele 2 and patients with CD but not with UC. Interestingly, the allele frequency and carriage rates of allele 2 were significantly higher in patients with CD than in patients with UC and in healthy subjects. Ethnic differences, genetic heterogeneity and sample size could be the reasons for such differences in comparison with studies from the West.     

Intestinal strongyloidiasis: a diagnosis frequently missed in the tropics

Strongyloides stercoralis, a nematode parasite, is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts hyperinfection and dissemination can occur, which has a high mortality. Early detection of S. stercoralis may alter the fatal course of infection. We present our experience of five patients with S. stercoralis hyperinfection diagnosed by endoscopic duodenal and jejunal biopsy in northern India. A predisposing factor was present in all patients in the form of corticosteroid intake, chronic liver disease and panhypogammaglobulinaemia. Common gastrointestinal symptoms were abdominal pain, diarrhoea, gastrointestinal bleeding, nausea, vomiting and weight loss with evidence of malabsorption. The initial stool examination and peripheral blood eosinophil count were normal in all patients. Strongyloidiasis was not suspected clinically in any patient and the diagnosis was achieved on endoscopic biopsy. Three of the patients with disseminated disease developed fatal Gram-negative systemic infection. This study highlights the importance of considering strongyloidiasis in all patients on immunosuppressive drug therapy who present with gastrointestinal symptoms so that the patient can be appropriately investigated and promptly treated. In endemic regions, patients with systemic Gram-negative bacterial infections without an obvious cause should be tested for strongyloidiasis.     

Emerging vancomycin resistance in enterococci in India

Infection caused by vancomycin resistant enterococci (VRE) leads to adverse outcome and is a real challenge. Despite increasing reports of VRE in different countries, there is scanty data on this issue from India. A total of 685 enterococci were isolated from various clinical samples from January to December 2004. Antimicrobial susceptibility was performed as prescribed by National Committee for Clinical Laboratory Standards (NCCLS). Vancomycin resistance was confirmed by minimum inhibitory concentration (MIC). Resistant phenotype was determined by Polymerase chain reaction (PCR). Of 685, 456 (67%) were E. faecalis and 229 (33%) were E. faecium. Resistance to various antibiotics in E. faecalis and E. faecium was as follows: ampicillin 33% and 54%, erythromycin 91% and 86%, ciprofloxacin 69% and 81%, tetracycline 50% and 54% and high level gentamicin resistance in 62% and 77% respectively. Vancomycin resistance was confirmed in 10 (1.4%) cases by MIC and all had Van A phenotype by PCR. Emergence of vancomycin resistant enterococci is of great concern because of its epidemic potential and scanty therapeutic options. Prompt diagnosis and efficient infection control measures can restrict its spread.     

CYP1A1 Msp1 T/C polymorphism in esophageal cancer: no association and risk modulation

Phase I enzyme CYP1A1 metabolizes environmental carcinogens and a Msp1 T/C functional polymorphism in 3'UTR in its gene has been reported to influence the inducibilty of the enzyme. There are controversies regarding association of the polymorphism with risk of esophageal cancer in Chinese and Caucasian populations. Moreover, no study has been done in Indian populations. The present study was aimed to explore the associations of CYP1A1 3'UTR polymorphism with clinical phenotypes and environmental interaction in esophageal cancer from North Indian population. A total of age- and gender-matched 161 cases and 201 healthy controls were used to genotype the CYP1A1 3'UTR polymorphism by PCR-EFLP methodology. None of the CYP1A1 genotypes and alleles was significantly associated with risk of esophageal cancer, even after adjusting for age and sex. After stratifying the genotypes according to disease characteristics such as tumor histology, location, and lymph nodes, individuals with TT genotype were at high risk for developing tumor in the upper third location (OR: 2.2, 95% CI: 0.81-6.2, p = 0.11). Interaction of tobacco usage (smoking or nonsmoking) and presence of occupational exposure in esophageal cancer patients did not show significant increase in cancer risk with CYP1A1 genotypes. However, in patients with alcohol habits, TT genotype showed a higher risk, which was not significant (OR: 2.5, 95% CI: 0.61-10.6, p = 0.19). In conclusion, CYP1A1 genotype did not influence the susceptibility of developing esophageal cancer. The presence of variant CYP1A1 genotypes together with environmental exposures also did not modulate the cancer risk.     

Acute hemorrhagic ascites: look beyond the gastrointestinal tract.

A 33-year-old alcoholic man presented with acute abdominal pain and hemorrhagic, high serum-ascitic albumin gradient ascites following an alcoholic binge, accompanied by hyperkalemia and azotemia. Spontaneous rupture of urinary bladder was diagnosed. The patient recovered uneventfully with conservative management.