Journal of Advances in Internal Medicine <p>Official journal of the Society of Internal Medicine of Nepal (SIMON). Full text articles available. Please submit manuscripts as email attachments to <a href=""></a>.&nbsp;The Ethics committee approval statement (IRC approval) is compulsory at the time of manuscript submission.</p> <p>The inaugural issue was published on February 10, 2012 with an initiative from Prof. Umid Kumar Shrestha, MD, PhD,&nbsp;Editor-in-Chief of Journal of Advances in Internal Medicine (J Adv Intern Med). The journal has since been publishing Original Articles, Review Articles, Case Reports, Medical Images, Editorials and others. The articles in the journal are&nbsp;licensed under a&nbsp;<a href="" rel="license">Creative Commons Attribution 4.0 International License</a>&nbsp;&nbsp;<a href="" rel="license"><img src="" alt="Creative Commons License">.</a></p> <p>Authors do not have to pay for the submission, processing or publication of articles in this journal.</p> Society of Internal Medicine of Nepal (SIMON) en-US Journal of Advances in Internal Medicine 2091-1432 Funny turns in Young badminton player: A case of cerebellar infarction secondary to vertebral artery dissection <p>Spontaneous vertebral artery dissection is a rare cause of cerebellar infarction. Common presentations of cerebellar artery infarction are dizziness and ataxia. We are reporting a case of a 31-year-old male who presented with acute onset dizziness while playing badminton, who was diagnosed as cerebellar vermis infarction secondary to vertebral artery dissection. &nbsp;</p> Bhupendra Shah Nawli Manandhar Raju Paudel Copyright (c) 2021 Bhupendra Shah, Nawli Manandhar, Raju Paudel 2021-12-31 2021-12-31 10 2 80 82 10.3126/jaim.v10i2.42194 Demystifying opportunistic infections in an AIDS patient of 21st century in Nepal <p>Currently, there is no cure for Human immunodeficiency virus /Acquired immunodeficiency syndrome (HIV/AIDS) but, there are medications to control HIV and prevent opportunistic infections. Clinicians must be vigilant enough to extract history and send relevant laboratory investigations to diagnose the disease in early stage. Patient may not have known his /her diagnosis or intentionally avoided to reveal the disease status which further complicates the diagnosis and treatment. This is case of a 51 years male, where social stigma forces the patient to hide his diagnosis and reluctant to seek medical treatment ultimately reaps the life. Hence, government and concerned authority must work up for wide availability of HIV/AIDS medications and motivate people to seek medical advices as soon as possible. Concerned authority must motivate people to consider it as any other treatable disease.</p> Sanjeet Bhattarai Devendra Shah Sulav Rayamajhi Yuvaraj Bhusal Kishor Khanal Prabhaw Upadhyaya Sanjeet Krishna Shrestha Copyright (c) 2021 Sanjeet Bhattarai, Devendra Shah, Sulav Rayamajhi, Yuvaraj Bhusal, Kishor Khanal, Prabhaw Upadhyaya, Sanjeet Krishna Shrestha 2021-12-31 2021-12-31 10 2 83 86 10.3126/jaim.v10i2.42195 Pseudocyst of Abdomen Presenting as a Huge Abdominal Mass after Ventriculoperitoneal Shunt: A Case Report <p>A ventriculoperitoneal shunt is a major surgical modality to relieve intracranial pressure in patients with hydrocephalus. Shunt obstruction and infection are the most common complications following shunt surgery whereas VP shunt-associated pseudocyst formation is a rare complication. These are the cystic space without the epithelial lining, filled with fluid around the distal tip of the catheter.</p> <p>In this case report, we present you a 47-year-old male who underwent VP shunt placed a year back presented with huge abdominal swelling, headache, and weight loss. CT scan of the abdomen showed abdominal pseudocyst with the peritoneal end of the shunt within the cyst.</p> <p>Though the exact mechanism is not known, abdominal adhesion, multiple revisions, obstruction, or dislodgement are thought to predispose to the formation of a pseudocyst.</p> Suman Adhikari Prabin Bhandari Balgopal Karmacharya Nikunja Yogi Copyright (c) 2021 Suman Adhikari, Prabin Bhandari, Balgopal Karmacharya, Nikunja Yogi 2021-12-31 2021-12-31 10 2 87 89 10.3126/jaim.v10i2.42197 Retrospective analysis of the role of Ulinastatin in reducing mortality in severe pancreatitis in critical care unit in Nepal <p><strong>Background:</strong> Acute pancreatitis sequelae require a multidisciplinary approach and ICU care. Ulinastatin is a serine proteases inhibitor that reduces inflammation by suppressing the infiltration of neutrophils and elastase release and inflammatory mediators that help improve clinical symptoms and reduce mortality. This study aims to evaluate the clinical utility of Ulinastatin.</p> <p><strong>Methods:</strong> Fifty-two patients admitted to ICU with acute pancreatitis were divided into; Ulinastatin group who received a 3 to 5 days course of 200,000IU, and Control Group who didn’t receive ulinastatin. Pearson's Chi-square and Fisher's exact test were used and a p-value &lt; 0.05 was considered statistically significant.</p> <p><strong>Results:</strong> Mean age was lower among the Ulinastatin group at 43 years (p-Value 0.014) and Hepatic dysfunction was more among this group (p-value 0.04). Among new onset of organ dysfunction, only CVS dysfunction was significant among the Control group ( p-value 0.044) while respiratory function recovery (p-value 0.04) and coagulation profile improvement (p-value 0.017) was statistically significant among the Ulinastatin group. The mean duration of hospital stay was shorter among control group, 9.65 days vs 14 days, a p-value of 0.05and also the average duration of stay in MDICU was lower, 4 days vs 8.5 days, p-value 0.0044 in comparison to Ulinastatin group. Overall mortality incidence was 15.38%, 19% in Ulinastatin group vs 11.5% in Control group.</p> <p><strong>Conclusion:</strong> This retrospective study is our experience in the use of Ulinastatin which has shown little efficacy in declining mortality and/or hospital stay duration though it helps prevent new organ dysfunctions.</p> Bikash Khadka Hemant Adhikari Saroj Poudel Kishor Khanal Copyright (c) 2021 Bikash Khadka, Hemant Adhikari, Saroj Poudel, Kishor Khanal 2021-12-31 2021-12-31 10 2 57 62 10.3126/jaim.v10i2.42154 Holter monitoring for assessment of possible paroxysmal atrial fibrillation as a cause in otherwise normal sinus rhythm patients with acute ischemic stroke: a hospital based study <p><strong>Background:</strong> Stroke/ cerebrovascular accidents are common and among the major causes of mortality and morbidity. Thromboembolism are also among the causes of ischemic strokes. Diagnosis of atrial fibrillation makes the difference in the management of ischemic strokes for long term as anticoagulation are given in these cases for prevention of further embolic events.</p> <p><strong>Methods:</strong> A prospective observational study was done from july 2019 to june 2021 for patients admitted for ischemic strokes who were otherwise found to have normal sinus rhythm. A 24 hour holter monitor was connected and analyzed for possible paroxysmal atrial fibrillation. Baseline investigations including trans-thoracic echocardiography was done. Data were analyzed and results were sought.</p> <p><strong>Results:</strong> Out of 212 patients admitted for stroke, only 116 were eligible for the study. Male female ratio was 2:1. Ninety-four percent of patients had at least one or more risk factors: Smokers (74%) followed by Hypertensives (70%), Dyslipidemics (54%) and Diabetics (20%). Twenty-two percent of patients were found to have paroxysmal atrial fibrillation. There was no gender difference between the occurrences of paroxysmal atrial fibrillation. Among the risk factors, smoking and hypertension were significantly associated with the occurrence of paroxysmal atrial fibrillation (P: 0.001 and 0.002 respectively) while other risk factors like diabetes and dyslipidemia had no significant association. There was significant association of paroxysmal atrial fibrillation with mortality (P: 0.0013).</p> <p><strong>Conclusion:</strong> Patients who are in otherwise normal sinus rhythm in electrocardiography with ischemic cerebrovascular accidents may have paroxysmal atrial fibrillation as cause of event. Smoking and hypertensive patients are significantly associated with occurrence of paroxysmal atrial fibrillation and stroke and these patients are more likely to die than the patients having normal heart rhythm. Management of these patients definitely defer in terms of possible use of anticoagulants.&nbsp;</p> Navaraj Paudel Namrata Thapa Ramchandra Kafle Subash Sapkota Abhishek Maskey Copyright (c) 2021 Navaraj Paudel, Namrata Thapa, Ramchandra Kafle, Subash Sapkota, Abhishek Maskey 2021-12-31 2021-12-31 10 2 63 66 10.3126/jaim.v10i2.42166 Magnetic Resonance Imaging Brain and Electroencephalogram (EEG) in the Evaluation of New-Onset Seizures in a Tertiary Care Centre of Nepal <p><strong>Introduction:</strong> Seizure is a common neurological condition with multiple etiological factors. This study aims to evaluate the role of magnetic resonance imaging (MRI) Brain and electroencephalography (EEG) in the diagnosis of new-onset seizures in the Nepalese population.</p> <p><strong>Methods:</strong> A total of 106 patients aged between 7 to 85 years of age with first onset seizure, who underwent MRI and EEG were enrolled in the study. The sensitivity of MRI and EEG for the diagnosis of seizure when used in combination was compared with that of MRI or EEG alone.</p> <p><strong>Results:</strong> Out of 106 patients, 58.5% (n=62) were males and 41.5% (n=44) were females. In 52.8% (n= 56) of the patients, there was epileptogenic lesion in MRI, and 39.6% (n=42) of the patients had an abnormal EEG. The combination of MRI with EEG was significantly better than either MRI or EEG alone in the diagnosis of seizures (p &lt;0.001).</p> <p><strong>Conclusion:</strong> MRI and EEG are frequently used for the evaluation of seizures. MRI Brain when used in combination with EEG significantly improves the diagnostic accuracy of seizures.</p> BR Pokharel P Upadhaya GR Sharma SJ Budathoki AMS Maharjan G Kharel S Phuyal Copyright (c) 2021 BR Pokharel, P Upadhaya, GR Sharma, SJ Budathoki, AMS Maharjan, G Kharel, S Phuyal 2021-12-31 2021-12-31 10 2 67 70 10.3126/jaim.v10i2.42171 Comparative Study of Electrocardiographic and Echocardiographic Evidence of Left Ventricular Hypertrophy in Systemic Hypertension <p><strong>Background and Aims:</strong> Hypertension is a common health problem. Left ventricular hypertrophy, a condition in hypertension is a risk factor for myocardial infarction, stroke and heart failure. This study aims to detect left ventricular hypertrophy in hypertensive patients using Electrocardiography and echocardiography.</p> <p><strong>Methods:</strong> In this descriptive cross-sectional study; 143 patients of Hypertension from February 2019 to August 2019 were enrolled. They were evaluated for left ventricular hypertrophy using electrocardiography and echocardiography. Sokolow-Lyon and Cornell Voltage electrocardiographic criteria were used and their sensitivities and specificities to detect left ventricular hypertrophy were calculated taking echocardiography as a gold standard method.</p> <p><strong>Results:</strong> The mean age of the study population was 58.69 ± 11.33 years. Mean duration of hypertension was 4.72 ±3.2 years. The mean systolic and diastolic blood pressure were 137 ± 15.42 mmHg and 84 ± 10.5 mmHg respectively. Out of 143 study population, 30(21%) of them had left ventricular hypertrophy on electrocardiography as defined by Sokolow-Lyon criteria, and 29(20.3%) had left ventricular hypertrophy on electrocardiography as per Cornell Voltage criteria. On combining both Sokolow-Lyon and Cornell Voltage criteria, 37(25.9%) of the study population had left ventricular hypertrophy on electrocardiography (either as per Sokolow-Lyon or Cornell Voltage criteria). On echocardiography, 62(43.4%) of them were found to have left ventricular hypertrophy.</p> <p><strong>Conclusions</strong>: Electrocardiography is a less sensitive tool to diagnose Left Ventricular Hypertrophy in hypertension but its specificity is high (&gt;95%). Investigation of choice to detect Left Ventricular Hypertrophy in hypertensive people is still the echocardiography.</p> Shyam Dhodary Surendra Uranw Naveen Kumar Pandey Prahlad Karki Copyright (c) 2021 Shyam Dhodary, Surendra Uranw, Naveen Kumar Pandey, Prahlad Karki 2021-12-31 2021-12-31 10 2 71 75 10.3126/jaim.v10i2.40289 Angiograhic profile and in-hospital outcome of young patients presenting with ST Elevation Myocardial Infarction (STEMI) in tertiary cardiac hospital <p><strong>Objective:</strong> To assess the angiographic profile and in hospital outcomes of primary percutaneous coronary intervention among young patients presenting with acute ST Elevation Myocardial Infarction and underwent primary PCI.</p> <p><strong>Methods:</strong> The retrospective observational study was conducted at Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, from july 2020 to June 2021, and included acute ST-Elevation Myocardial Infarction patients underwent primary percutaneous coronary intervention (PCI). Data was collected on demographic, angiographic, and in-hospital outcomes. Patients &lt;45 years were considered young. Data was analysed using SPSS 21.</p> <p><strong>Results:</strong> Total 104 patients met the inclusion criteria. Mean age of presentation was 40.16 ± 4.42 years. Over three-fourth of the patients were male 80 (76.9%). Smoking was the most prevalent risk factor with 61 (58.6%) patients followed by hypertension 35 (33.6%) and dyslipidemia 23 (22.1%). Single Vessel Disease (SVD) was the most common finding seen in 62 patients (59.6%) and Left Anterior Descending Artery (LAD) was the most commonly involved artery seen in approximately three fourth patients 80 (76.9%) followed by RCA 61 (58.6%) and LCX 15(14.4%). Left Main Coronary Artery is involved in 3 patients (2.9%). 6 (5.8%) patients suffered from cardiogenic shock either at admission or during hospital stay. Total In hospital mortality was seen in 3 (2.9%) patients.</p> <p><strong>Conclusions:</strong> Among young patients (&lt;45 years old) with STEMI who underwent PPCI in underdeveloped country majority are males and smoking is the most prevalent risk factor. Single vessel disease and LAD involvement is the most common angiographic finding and they have favorable in-hospital outcome.</p> Rabindra Pandey Arun Maskey Bishal Shrestha Arjun Budhathoki Sabindra Bhupal Malla Bibek Baniya Surendra Bhatta Sashit Shrestha Parveen Kumar Yadav Copyright (c) 2021 Rabindra Pandey, Arun Maskey, Bishal Shrestha, Arjun Budhathoki, Sabindra Bhupal Malla, Bibek Baniya, Surendra Bhatta, Sashit Shrestha, Parveen Kumar Yadav 2021-12-31 2021-12-31 10 2 76 79 10.3126/jaim.v10i2.42175 The efficacy of combined Albendazole and Praziquantel therapy versus Albendazole monotherapy in treatment of parenchymal neurocysticercosis: A systematic review <p>Preliminary studies suggest combined albendazole and praziquantel (ABZ+PZQ) therapy has superior anti-parasitic effect compared to albendazole (ABZ) or praziquantel (PZQ) monotherapy, due to potential pharmacokinetic synergism. We thus present an evidence-based review evaluating the risks and benefits associated with combination ABZ+PZQ therapy compared to standard ABZ monotherapy in the treatment of viable parenchymal Neurocysticercosis (NCC). Our systematic review is based on PRISMA (Preferred Reporting Items for Systematic review and Meta- Analysis) statement. Our primary outcome measure was to compare the efficacy of ABZ+PZQ with ABZ alone for treatment of NCC. Efficacy was determined based on clinical and radiographic evaluation. The secondary outcome measured the incidence of adverse effects in each treatment group. Literature search yielded a total of 120 articles. After excluding duplicates and those not meeting inclusion criteria, five papers were reviewed for data collection. Medication regimens, number of cyst, patient age, and location varied amongst included papers. The combination therapy resulted in significant symptom and cyst resolution in patients with more than two viable parenchymal cysts as compared to monotherapy. The two treatment arms were comparable in treating NCC with low cyst burden. There was no significant difference in the adverse effects between two treatment groups. In individuals with multi-cystic NCC, the patients who received dual therapy had better outcomes than those who received ABZ monotherapy as evidenced by radiographic improvement and reduced seizure episodes. The adverse effect profile in patients receiving dual therapy was similar and comparable to those with monotherapy.</p> Gaurav Nepal Jessica Holly Rehrig Rajan Sharma Kandel Shaik Tanveer Ahamad Bipin Kandel Rajeev Ojha Jayant Kumar Yadav Sujan Jamarkattel Ravi Shah Jeevan Gautam Gentle Sunder Shrestha Copyright (c) 2021 Gaurav Nepal, Jessica Holly Rehrig, Rajan Sharma Kandel, Shaik Tanveer Ahamad, Bipin Kandel, Rajeev Ojha, Jayant Kumar Yadav, Sujan Jamarkattel, Ravi Shah, Jeevan Gautam, Gentle Sunder Shrestha 2021-12-31 2021-12-31 10 2 90 96 10.3126/jaim.v10i2.38477 Neurological manifestations of COVID-19: A literature review <p>A novel coronavirus that started from the Wuhan province of China is affecting the whole world. As of this date, more than 222 million cases are reported with more than 4.60 million fatalities. Nepal has more than 771,000 cases reported with almost 11,000 death recorded to date. Though most of the patients present with flu-like symptoms, people with comorbidities like Diabetes mellitus, hypertension, lung, and heart disease most likely suffer from severe disease and even death. As reported, neurological manifestations are common in critically ill patients. The most common manifestation of CNS is headache, dizziness, and encephalopathy whereas loss of smell and taste is the common PNS manifestation. Other neurological complications seen are fatigue, myalgias, hemorrhage, altered consciousness, Guillain-Barre Syndrome, syncope, seizure, and stroke. Non-specific neurological symptoms may be present in the early stages which can mislead the treatment. In some cases, neurological manifestations precede the typical presentation of fever, cough, and shortness of breath and later develop into typical features. The virus enters the brain through 2 systems: hematogenous route or olfactory route. Angiotensin-converting enzyme-2 (ACE-2) is the port of entry to the brain for COVID- 19(SARS-CoV-2) which was also the entry point for SARS-CoV. Covid-19 cases are increasing in the world and prevention and control of spread are a must. Understanding the neurological invasion pathogenesis, and manifestation will help the neurologists and physicians on frontlines to recognize early cases with nervous system involvement, neurological complications, and sequelae during and after the pandemic.</p> Suman Adhikari Prabin Bhandari Naresh Poudel Nikunj Yogi Balgopal Karmacharya Asmita Dhakal Copyright (c) 2021 Suman Adhikari, Prabin Bhandari, Naresh Poudel, Nikunj Yogi, Balgopal Karmacharya, Asmita Dhakal 2021-12-31 2021-12-31 10 2 97 102 10.3126/jaim.v10i2.42199 Monoclonal Antibody Cocktail therapy for COVID-19: A Pharmacological innovation <p>The novel SARS-CoV-2 infection has ripped through international health systems and protocols causing unprecedented mortality, morbidity and global trade deficits amounting to billions. Various monoclonal antibodies have been proposed for use in the treatment of COVID-19 infections. One such drug is LY-CoV555 which in an ongoing phase two trial study conducted by Chen P et al, showed to have an elimination of 99.97% of the viral RNA. The monoclonal antibody 47D11 discovered by Wang et al, binds to SARS-CoV-2. The 47D11 has been reconfigured into a human IgG1 isotope. It has shown that the 47D11 mAb effectively neutralizes the SARS-COV-2 virus. The stance and development however for the treatment of COVID-19 with monoclonal antibodies has shifted from a monotherapy to a so-called monoclonal antibody “cocktail” therapy.</p> <p>REGN-COV2 is such a cocktail developed with the use of two monoclonal antibodies REGN10987 and REGN10933 which have subsequently been named Imdevimab and Casirivimab. REGN-COV2 is currently under study in four phase 2 and 3 trial studies. These studies are multicentric in nature and are being conducted to evaluate the drug’s efficacy, dosing and clinical use as compared to the placebo. The mechanism of action of such monoclonal antibodies is related chiefly to the inhibition of the virus’s ability to perform its invasion and multiplication within the human body.</p> <p>The severity coupled with the sheer novelty of the SARSCoV-2 virus demands the use of newer therapies to both decrease the mortality and morbidity in patients suffering from the infection. The use of a combination of monoclonal antibodies is thereby well established and evident to both decrease the viral infection load, but is also useful in disrupting the virus’s life cycle and thus decreases the replication and viral shedding. It is therefore poignant that a combination of monoclonal antibodies, a “cocktail” therapy is employed so as to attack the virus at its various stages and thus this multifaceted approach may enhance the patient’s prognosis.</p> Jared Robinson Indrajit Banerjee Copyright (c) 2021 Jared Robinson, Indrajit Banerjee 2021-12-31 2021-12-31 10 2 103 105 10.3126/jaim.v10i2.42200