Journal of Advances in Internal Medicine

Small Volume Plasma Exchange as an Alternative to Conventional Plasma Exchange and Intravenous Immunoglobulin for Myasthenic Crisis: A Case Report

Ankit Rimal — 2023-02-12

Myasthenic crisis is a life-threatening condition. At times it manifests as the initial presentation of the underlying myasthenia gravis. Rapidly acting therapies for treatment of this condition are plasma exchange and intravenous immunoglobulin. We report a case of myasthenic crisis in a young female, presenting with respiratory failure and bulbar symptoms. She had significantly raised titres of anti-acetylcholine receptor antibody. She was treated with multiple sessions of small volume plasma exchange. This modification of conventional plasma exchange significantly reduces costs and is potentially an effective alternative to conventional plasma exchange and intravenous immunoglobulin in resource-poor settings.

A Case of Relapsing Polychondritis with Tracheobronchial Involvement

Naresh Gurung — 2023-02-12

Relapsing Polychondritis (RPC) is a rare systemic inflammatory disorder of unknown etiology and characterized by recurrent and progressive inflammation of the cartilaginous structures, particularly involving the auricles, nose and respiratory tract as well as extra-cartilaginous tissues, including eyes, heart, skin, central nervous and hematological systems. Its diagnosis can be difficult when the typical clinical features such as auricular chondritis are absent. Here, we report on a case of 43-year-old woman who presented with recurrent sore thorat, dysphagia, extertional dyspnea, cough and noisy breathing initially misdiagnosed as acute laryngitis who was eventually diagnosed as Relapsing polychondritis with tracheobronchial involvement. Chest computed tomography showed the diffuse involvement of tracheobronchial cartilage. Based on the, Damiani’s criteria, she was diagnosed as relapsing polychondritis even though there was no unique involvement of auricular cartilage, and high dose steroid and immunosuppressive therapy were then started. This case indicated that patients who have tracheobronchial cartilage involvement without definite auricular chondritis should be considered for relapsing polychondritis as a differential diagnosis. This case is reported to raise awareness of airway involvement in RPC and discuss its current management.

Dengue Fever Presenting as Acute Pancreatitis: A Case Series

Kishor Khanal — 2023-02-12

Acute pancreatitis (AP) is a rare complication of Dengue fever with unpredictable progression and outcome. There have been increasing reports of acute pancreatitis due to dengue. Fever, abdominal pain or tenderness are the presenting clinical manifestations on hospital admission. We reported two similar cases of Dengue who presented with the complaints of fever, abdominal pain, and generalized body ache. Acute pancreatitis was diagnosed in both cases following blood investigations, ultrasound and contrast enhanced computed tomography (CECT) of the whole abdomen.

Premature or due End of COVID-19

Jared Robinson — 2023-02-12

The SARS-CoV-2 virus has been a part of our daily lives since its inception towards the latter part of 2019. The global journey throughout the pandemic has been one of numerous steps in progression and steps in regression and can be described as a roller-coaster like ride. The majority of the global populous is currently in phase 4 of the SARS-CoV-2 pandemic. Phase 4 involves preparing and investing in further research and development of infrastructures to prevent such pandemics and outbreaks in future. The continued global COVID-19 vaccination campaigns and the booster doses offered therein are the greatest weapon being wielded to control and now ultimately end the global pandemic. According to the WHO the total weekly COVID cases have been decreasing on a constant scale with the latest (19 of September 2022) reported weekly update depicting a deficit of 281745 cases (an 8.3% reduction from the previous weekly statistics). In contrast to the positive direction of movement of COVID cases on a generalized basis, The United Kingdom’s cases seem to be regressing. Although the global COVID picture is showing very positive signs, the global populous must not be lulled into a false sense of security as the globe experienced first-hand what the discovery of a new variant can do to both the infection rates as well as global financial and fiscal markets, as with the Omicron variant in December of 2021. The COVID-19 pandemic is in its final stages; however, a continued and orchestrated global effort is pertinent to ensuring that the pandemic is truly ended and that no unexpected flare ups occur. A continued global vaccination effort will be key to not only ending this pandemic, but to also preventing such future occurrences. The single greatest threat to truly ending this current pandemic is the premature declaration that it is over.

Inflammatory Biomarkers in COVID-19: Associations with Clinical Characteristics and Outcomes among COVID 19 Patients Hospitalized in Sukraraj Tropical and Infectious Disease Hospital

Sanjay Shrestha — 2023-02-12

BACKGROUND Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus referred to as SARS-CoV-2. Biomarkers has been linked with severity and appears to influence clinical outcomes among COVID-19 patients.
Aims: This study aimed to describe the association of inflammatory biomarkers with clinical characteristics, severity and outcomes among COVID 19 patients in a tertiary tropical and infectious disease hospital in Nepal.

METHODS This was a retrospective observational study where medical and lab records of COVID-19 inpatients (patients tested positive for SARS-CoV-2 via reverse transcriptase-polymerase chain reaction (RT-PCR)) admitted between April 2021 and September 2021 at Sukraraj Tropical and Infectious Disease Hospital, representing the second wave of COVID-19 were reviewed. Medical records of the patients were collected till discharge and inflammatory biomarkers were evaluated in relation to clinical presentations, severity and outcome among patients. Statistical analysis was done using SPSS 23.

RESULTS A total of 628 COVID-19 confirmed patients admitted in the study period were included in the study, 487 patients (77.5%) improved, 118 (18.8%) expired, and 23 (3.7%) were referred. Severity at presentation was significantly associated with Ferritin (p 0.013), CRP (<0.001), D-dimer levels (0.003) and Neutrophil-to-Lymphocyte ratio (NLR) (<0.001). Fever was found to have significant association with CRP (p<0.001) and ferritin (p 0.004), but not with D-dimer (p 0.587). Non-survivors were found to have significant association with higher ferritin (p <0.001), CRP (p<0.001), D-dimer (p <0.001) and NLR (<0.001). The duration of hospital stay was significantly affected by D-dimer (p 0.001) and CRP levels (p<0.001). Similarly need for mechanical ventilation had significant association with higher levels of Ferritin (p 0.002), CRP (p<0.001), D-dimer (p<0.001) and NLR (<0.001). Serial recordings of D-dimer showed increasing values had significant association with poor outcome (p<0.001).

CONCLUSION Higher values of D-dimer, ferritin, CRP and NLR were associated with higher severity of the COVID-19 disease and poor clinical outcomes including higher duration of hospital stay, higher need for mechanical ventilation and morbidity. Early stratification of disease based on biomarkers can guide early intervention to prevent bad outcomes.

Clinical profile of critically ill patients admitted with Dengue in a tertiary level hospital in Nepal: A retrospective study

Gentle Sunder Shrestha — 2023-02-12

BACKGROUND AND AIMS Dengue is a viral disease transmitted by mosquitoes. The burden of disease related to Dengue is considerable in tropical and sub-tropical countries. Recently, many countries observed the outbreak of Dengue. Our study aims to explore the clinical profile and outcome of the dengue positive cases admitted in the intensive care unit (ICU) of a tertiary level hospital in Lalitpur.

METHODS We conducted a retrospective single center study in patients with proven Dengue, admitted to ICU. Data were collected between 20th August and 15th October 2022. Data collected were the baseline characteristics of patients, signs and symptoms and need for organ support. Patients were graded according to WHO severity scale.

RESULTS A total of 31 cases were admitted during the study period. Fever, vomiting and malaise were the common presenting symptoms. Comorbidities like hypertension and diabetes were common. Hypotension, requiring inotropic support was present in nine (29.0%) of cases. Ten patients (32.3%) required respiratory support. Derange hepatic and renal function were common. Five patients (16.1%) presented with clinically significant bleeding. Six (19.4%) of the cases expired in ICU. Among the non-survivors, five (83.3%) had severe Dengue and one (16.7%) case had Dengue with warning signs.

CONCLUSION Critically ill patients with Dengue have multisystem involvement. Severe Dengue and Dengue with warning signs is associated with significant morbidity and mortality.

An Echocardiographic Evaluation of Cardiopulmonary Evaluation of Cardiopulmonary Functions in Patients with Cirrhosis of Liver and Correlation with Severity of Disease

Hari Prasad Panthi — 2023-02-12

BACKGROUND Cirrhosis is the end result of varieties of chronic liver disease. A large proportion of patients with cirrhosis develop cardiopulmonary complication. The aim of this study was to evaluate the cardiopulmonary functions of patient with cirrhosis of liver and to correlate these abnormalities with CTP and MELD score.

METHODS The study involved 81 cirrhotic patients admitted in Department of Gastroenterology of TUTH over a period of one year. The diagnosis of cirrhosis was established and clinical evaluation and investigation done.

RESULTS The mean age of cirrhotic patients included in the study was 52 years. Alcohol was most common cause of cirrhosis (75.31%). The mean CTP score and MELD score was 10.02±1.77 and 23.59±7.53 respectively. Thirty patients (37.03%) had prolonged QTc interval, which had statistically significant association with alcohol as etiology of cirrhosis (p = 0.04). More than half (50.62%) of patients had diastolic dysfunction but it was not statistically significantly associated with CTP and MELD-Na score. Seven patients had evidence of intrapulmonary shunting, which had statistically significant association with MELD-Na score (p =0.01). Similarly, total 5 patients (6.17%) had PPHTN but there was no statistically significant association with CTP and MELD-Na score. Seventeen patients had dilated left atrium with no statistically significant association with CTP score and MELD-Na score.

CONCLUSION There was significant incidence of cardiopulmonary abnormalities in cirrhotic patients. Every patient with decompensated cirrhosis irrespective of severity of disease should be evaluated for cardiopulmonary complication with a noninvasive, real-time, rapid imaging transthoracic contrast echocardiography.

Gastrointestinal and Hepatic Manifestations in Patients with Covid-19

Bhawesh Thapa — 2023-02-12

BACKGROUND Gastrointestinal symptoms and Liver injury have been frequently described in patients with COVID-19.In this study, we aim to study the prevalence of Gastrointestinal symptoms and Liver injury and their impact on disease severity and clinical outcomes.

METHODS This is a descriptive, cross sectional observational study done in 195 patients admitted to Bir Hospital with Corona virus Disease-19(COVID-19) from May 2021 to July 2021.Patients presenting symptoms and liver function tests (LFTs) were noted at admission. Gastrointestinal symptoms were defined as the presence of one of Nausea, Vomiting, Abdominal pain or Diarrhea. Liver injury was defined as elevation of Total Bilirubin > 1mg/dl or Alanine transaminase (ALT) >40U/L, Aspartate Transaminase(AST) >40U/L or Alkaline Phosphatase(ALP)>135 U/L. Patients were followed during hospitalization and outcomes assessed at discharge.

RESULTS Gastrointestinal symptoms were present in 32.3% among which Nausea (27.7%) was the commonest. There was no significant association of Gastrointestinal symptoms with duration of hospital stay, ICU admission or mortality. Liver injury was present in 72.8% patients and significantly more in those with GI symptoms than without GI symptoms. Patients with liver injury had a significantly longer hospital stay (8.92 ± 3.7 days vs 6.70±3.2 days, p=0.004), higher ICU admissions (38.02% vs 7.54% p=0.000018) and mortality (23.23% vs 1.88%, p=0.001) compared to patients with normal LFTs.

CONCLUSION Gastrointestinal symptoms and Liver Injury are common in patients with COVID-19. Liver injury at admission is associated with severe disease and higher mortality. More attention should be given in the care of such patients to avoid poor outcomes.