Journal of the Nepal Medical Association

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Takotsubo disease.
(2007-08-28) Nepal, M
Tako-tsubo cardiomyopathy, a novel heart syndrome with peculiar variant of left ventricular dysfunction, characterized by preferential apical dyskinesis and basal hyper contractility has been described on numerous occasions especially in persons without obstructive coronary artery disease. It is considered of reversible etiology and seems to have increased predisposition in elderly, stress-ridden females. Although Tako-tsubo cardiomyopathy was described initially in patients of Japanese origin, its existence in white populations in both Europe and the US have recently been documented. Simultaneous multivessel coronary spasm of the epicardial coronary microvessels is believed to be a major contributor. However, this pathophysiologic basis for this phenomenon has not been validated universally throughout literature. Another potential mechanism of events that seems to be responsible for this phenomenon is the transient myocardial stunning associated with hypersensitivity to catecholamine. The clinical presentation usually simulates that of an acute ST- elevated myocardial infarction but the coronary angiography by definition shows no critical lesions. Patients surviving acute episode usually recover fully in few weeks. Acute onset of cardiogenic shock in a person without coronary risk factors should raise the possibility of this rare type of entity but should not withhold the acute treatment. Prognosis generally varies and has largely been good. Takotsubo though largely benign may be fatal sometimes.
Serum urea, creatinine and electrolyte status in patients presenting with acute gastroenteritis.
(2007-03-06) Kc, M; Gurubacharya, D L; Lohani, R; Rauniyar, A
The present study was undertaken to estimate the serum urea, creatinine and electrolyte status of patients presenting with acute gastroenteritis. Sixty patients who presented to Kathmandu Medical College and Teaching hospital from 15 June to 15 July 2005 with acute diarrhea with or without associated vomiting, causing dehydration severe enough to require hospital admission were investigated for serum urea, creatinine and electrolyte level. Out of 60 patients investigated, serum sodium and potassium level were available for 34 patients. Only one (2.9%) patients had sodium level below 135mEq/l, thirty two (94.11%) had sodium level between 135-146 mEq/l and one (2.9%) had sodium level above 146mEq/l. Similarly 9 (26.47%) patients had potassium level below 3.5mEq/l, 22 (64.70%) patients had potassium level between 3.5-5 mEq/l and 3 (8.82%) patients had level above 5 mEq/l. Serum urea and creatinine level were available for 47 patients. 36 (76.59%) patients had serum urea level between 15-45mg/dl and 11 (23.40%) patients had urea level above 45 mg/dl. 35 (74.46%) patients had serum creatinine level between 0.5-1.4 mg/dl and 12 (25.53%) had serum creatinine level above 1.4 mg/dl. In this study hypokalaemia was noticed more than hyponatremia and significant number of patients also showed increased level of serum urea and creatinine. Therefore, serum urea, creatinine and electrolytes should be closely monitored in patients with acute gastroenteritis.
Mammographic diagnosis of breast carcinoma: an institutional experience.
(2008-08-19) Sidhartha,; Thapa, B; Singh, Y; Sayami, P; Khanal, U
Mammogram is a common diagnostic modality for breast carcinoma. Diagnostic mammogram is available at only few centers in Nepal. The aim of this study was to determine the accuracy of diagnostic mammogram in Nepalese women suffering from breast carcinoma. A retrospective analysis of the breast carcinoma was carried out in the Department of Surgery, Tribhuwan University Teaching Hospital from October 1995 to October 2007. Out of 556 patients with histologically proven breast carcinoma, 378 patients (68%) had undergone mammography. Breast carcinoma was identified on mammography in 328 (87%) cases while 50 cases (13%) were reported as normal or benign lesions. Diagnostic mammogram had a sensitivity of 86.8%, a specificity of 98.6% with a positive predictive value of 68.8% and a negative predictive value of 99.5%. In mammographically missed breast carcinoma, 34% were less than 40 years of age (P<0.05), 60% were premenopausal (P<0.05) and 88% patients presented with a painless lump. The study shows that the diagnostic accuracy of the mammogram is very high. However, there is a chance of missing the breast carcinoma in young and premenopausal women.
Patient information leaflets in surgical practice: a contemporary review.
(2007-12-21) Shrestha, B M
Undergoing any surgical procedure, however minor this may be, generates a certain degree of anxiety amongst the patients, which is primarily related to the possible postoperative course and complications. Introduction of Patient Information Leaflets (PIL) in routine surgical practice has helped ameliorate this problem significantly and therefore has become a standard practice in the United Kingdom and elsewhere. This review highlights the evidence available in support of the use of PIL and outlines the process of development of PIL in surgical practice.
Osteosarcoma in pregnancy.
(2006-03-24) Nepal, P; Singh, G K; Singh, M P; Bajracharya, S; Khanal, G P; Pandey, S R
Osteosarcoma in pregnant women is rare. Delay in diagnosis may be due to lack of any signs or symptoms during gestation, clinical misdiagnoses, religious attitude and refusal of the patients. Most cases soft-tissue and bone tumors during pregnancy can be managed successfully with surgery during gestation. Therapies with fetal toxicity were more likely to be deferred to postpartum period. This case is rare and liable to be missed, hence is reported.
Behcet's Disease : report of a case and review of the literature.
(2007-08-07) Wallis, S; Macierewicz, J; Shrestha, B M
Behcet's disease (BD) is an autoimmune disease of unknown aetiology with multisystem involvement presenting with relapsing orogenital ulcers and uveitis, involvement of central nervous system, joints, lungs, gastrointestinal tract and major blood vessels leading to myriads of presentations, which requires a multidisciplinary approach for satisfactory outcome. We describe a patient with BD, highlight its pathophysiology and management aspects, and present review of pertinent literature.
HIV / AIDS in Nepal: an update.
(1994-07-01) Suvedi, B K; Baker, J; Thapa, S
HIV/AIDS is a growing problem in Nepal. There has been a 15-fold increase in the number of HIV-infected cases during the period 1990-93. By 1993, 195 cases had been reported to the Ministry of Health. Among the total cases reported, approximately equal numbers of male and female HIV cases are represented. The current estimate of HIV-infected individuals is 5000; however, the number is projected to reach cumulatively 100,000 by the year 2000 if effective preventive measures are not taken. Commercial sex workers and their clients remain the most affected groups. The majority of HIV-infected cases belong to the 20-29 age group. HIV surveillance data indicate that the overall positivity rate increased from 0.20 to 0.70 over the 12-month period, 1991-92. Of the total 195 HIV-infected cases, 24 (12.3%) are reported to be AIDS cases. The AIDS cases doubled between 1991 and 1993. There are three times as many AIDS cases among females than males. Of the total 24 AIDS cases, 11 have died. Case studies illustrate the multi-faceted context in which HIV/AIDS is spreading in Nepal.
Children with first episode of fever with seizure: is lumbar puncture necessary?
(2008-12-17) Joshi Batajoo, R; Rayamajhi, A; Mahaseth, C
Fever with seizure, a common presentation with which a child may present to the emergency is mainly due to febrile seizure, but it may also be due to meningitis. This study was done to find out the incidence of meningitis and to find out whether lumbar puncture is necessary in different age groups of children presenting with first episode of fever with seizure. A prospective study was conducted in the emergency department of Kanti Children's Hospital. Children who presented with first episode of fever and seizure in the age group of 6 months to 5 years were included. Meningitis was diagnosed on the basis of either cytological and biochemical criteria or if a bacterial pathogen was isolated. Of the 175 children included, 17% were diagnosed to have meningitis. Cerebrospinal fluid was positive for a bacterial pathogen in 4.5% of the cases. In the age group of 6 months to 12 months, 30% of the children had meningitis as compared to 20 % and 5% in other age groups of 12- 18 months and above 18 months respectively. All children with culture proven bacterial meningitis were in the age group of 6-12 months and had no evidence of meningeal irritation. Signs of meningeal irritation had high specificity in diagnosing meningitis. Organisms grown were Haemophilus influenza in three cases, Streptococcus pneumoniae in two cases and Staphylococcus aureus in three cases. In conclusion, incidence of meningitis was found to be high in children presenting with first episode of fever and seizure. Lumbar puncture to rule out meningitis should especially be considered in children in the younger age group even without evidence of meningeal irritation.
Sympathetic ophthalmia : a blinding complication of ocular injury.
(2006-03-24) Subedi, S
Sympathetic Ophthalmia is a rare and blinding ocular complication due to ocular injury. This condition in a male patient aged 25 years, is reported. The role of early recognition and management of this condition to preserve good vision is discussed.
Intraluminal migration of Gossypiboma without intestinal obstruction for fourteen years.
(2008-12-17) Kansakar, R; Thapa, P; Adhikari, S
A 55 years lady presented with dull aching right upper abdominal pain with intermittent episodes of diarrhea following cholecystectomy which she underwent fourteen years back. Ultrasound and computed tomography findings were suggestive of foreign body in right subhepatic space. Exploratory laparotomy revealed circumvented loop of ileum with intra luminal mass sized 5 x 10 cm, resection anastomosis of the segment of ileum was performed. When opened it contained a surgical sponge with no external communication but an internal fistulous tract was present between the proximal and distal loops beyond the mass. Though intraluminal migration of retained surgical sponge has often been reported, complete intraluminal migration without features of obstruction or external opening is rarely seen.
Chest radiographs and their reliability in the diagnosis of tuberculosis.
(2006-06-06) Kumar, N; Bhargava, S K; Agrawal, C S; George, K; Karki, P; Baral, D
Radiology plays an important role in the diagnosis of pulmonary tuberculosis. Many medical practitioners believe in and rely primarily on the chest x-ray for the diagnosis of pulmonary tuberculosis. This study attempts to evaluate the reliability and validity of chest radiographs. This study was carried out in the tuberculosis clinic of BPKIHS. 75 radiographs were chosen for the study and viewed by 25 physicians of varying qualifications. Their findings were compared with the gold standard. The overall sensitivity and specificity was 78% and 51% respectively. There was poor agreement between the best physician and the best radiologist. This study has demonstrated an unsatisfactory sensitivity and specificity of chest x-rays in the diagnosis of pulmonary tuberculosis. The over-diagnosis and over-treatment due to chest x-rays could lead to an unmanageable burden on the resources of a poor country like Nepal. Private practitioners should be made aware about the importance of bacteriological diagnosis of tuberculosis before initiating drug therapy.
Etiological pattern of blepharoptosis among patients presenting in teaching hospital.
(2006-12-27) Thapa, R; Karmacharya, P C; Nepal, B P
The purpose of this study was to find out the etiological pattern of blepharoptosis among patients presenting in BPKLCOS, T.U. Teaching Hospital. This was a hospital based descriptive and cross-sectional study conducted from February 2003 to July 2004. A total of 125 patients with ptosis were evaluated. 78 cases (62.4%) were congenital and 47 cases (37.6 %) were acquired. Congenital simple ptosis and congenital complicated ptosis comprised of 58% and 42% respectively. Among the acquired cause, ptosis due to trauma was the commonest 32%, followed by third cranial nerve palsy 25.5%, myasthenia gravis 17%, aponeurotic 10.7%, chronic progressive external ophthalmoplegia 8.5% etc. Aetiology-wise, myogenic ptosis was the commonest (65.6%) which was followed by neurogenic (16.8%), traumatic (12%) and aponeurotic ptosis (5.6%). Congenital ptosis is more common than acquired ptosis. Myogenic ptosis is the most predominant type of ptosis. Among the congenital ptosis, congenital simple ptosis is more common than congenital complicated ptosis. Among the acquired cases trauma, third cranial nerve palsy and myasthenia gravis are the major attendees.
Spontaneous intracystic hemorrhage of the arachnoid cyst: a case report and review of literature.
(2008-12-17) Jha, R; Sharma, G R; Kumar, P; Roka, Y B
Arachnoid cysts represent benign cysts that occur in the cerebrospinal axis in relation to the arachnoid membrane and do not communicate with the ventricular system. We report a case of a years right handed lady, who presented to the emergency department with the complaints of headache and vomiting for one week CT scan showed extraaxial cystic lesion in the left fronto-parietal region. On the fifth day of admission, patient had sudden onset of severe headache associated with loss of consciousness for about 3-4 minutes with neck rigidity. A CT scan of head was repeated, which showed left fronto-parietal cystic lesion with intracystic bleed and SAH. Intraoperatively, there was intradural cystic lesion containing xanthochromic fluid with normal brain surface and there were no evidence of any vascular malformations. Marsupilization of the cystic lesion was carried out and she improved. The literature regarding arachnoid cyst with spontaneous intracranial haemorrhage is reviewed.
Simultaneous occurrence of glioblastoma at mirror image site in siblings.
(2007-08-07) Sharma, V; Huda, M F; Singh, K; Kumar, M
Two brothers (eight and ten years) presented at the same time with features of raised intracranial pressure and found to have glioblastoma multiforme at mirror image site in parieto-occipital lobe.
Cushing's Syndrome : an overview.
(2007-08-07) Cincu, C; Agrawal, A
Cushing's syndrome is the collection of symptoms and signs caused by chronic elevation of circulating free cortisol. Since the first description of the syndrome, results from long-term exposure to glucocorticoids has not been improved upon, but our understanding of its pathophysiologic features and our ability to diagnose and treat the disorder have increased dramatically. In this article we review the current literature about Cushing's syndrome.
Primary malignant melanoma of vagina--a case report with review of literature.
(2008-03-15) Ghosh, A; Pradhan, S; Swami, R; Kc, S R; Talwar, O
Primary vaginal malignant melanoma is a very rare tumor with less than 300 cases reported to date. We describe a case of primary vaginal melanoma and review the literature. A 60 years postmenopausal female patient presented with painless mass coming out of the vagina with occasional bleeding for last 2-3 weeks. On vaginal examination there was a firm polypoidal growth of size 7 cm attached to the right lateral wall of vagina and coming out of the introitus. Histopathology of the mass showed features of malignant melanoma. Wide local excision was done and adjuvant therapy was given. However patient came back after three months with widespread metastasis and expired 6 months after the initial diagnosis. Vaginal melanoma is a very aggressive tumor and the overall prognosis is very poor despite the treatment modality.
Antenatal detection of conjoined twin.
(2008-02-16) Sharma, U K; Dangol, A; Chawla, C D; Shrestha, D
Conjoined twin is a sporadic event with prevalence of 1 in 50000 to 1000000 birth. Incomplete division of embryonic disc results in conjoined twin. Ultrasound plays a major role for early detection and proper obstetric management. A case of cephalothoracopagus conjoined twin was detected at 20 weeks pregnancy in a primigravida woman by antenatal ultrasound. The pregnancy was terminated after proper counseling, despite the need to save the baby, as multidisciplinary team to separate the twins was not available.
Erosive oral lichen planus and its management: a case series.
(2008-08-19) Sharma, S; Saimbi, C S; Koirala, B
Lichen planus (LP), although a dermatosis, is more common in the oral mucous membrane than in the skin. Lesions of oral LP are classically found on the buccal mucosa and gingiva. Among the various types, the reticular lesions are asymptomatic and require no treatment, but pain and severe discomfort accompany the erosive or ulcerative lesions. Malignant transformation to squamous cell carcinoma developing in areas of erosive oral LP (EOLP) being a possibility, it is important for clinicians to maintain a high index of suspicion for all intraoral lichenoid lesions. Therefore, periodic follow-up of all patients with EOLP is recommended. In view of the above, this paper highlights the management of four cases of EOLP with topical corticosteroid and CO2 laser surgery.
Acute liver failure caused by hepatitis E virus and paracetamol.
(2007-12-21) Kc, S
Acute liver failure is characterized by severe and sudden liver cell dysfunction leading to hepatic encephalopathy and hepatic coagulopathy in a person without history of liver disease in the past. This catastrophic illness can rapidly progress to coma and death from cerebral edema and multi organ dysfunction. It carries a high mortality rate if liver transplantation is not carried out. In West, paracetamol is the main cause of hepatotoxicity whereas in the East viral hepatitis tops the list. This report describes a case of acute liver failure in which probably both the agents were involved. The patient recovered with antidote therapy and maximum supportive care.
Prevalence of pulmonary tuberculosis in far Western Nepal.
(2006-03-24) Joshi, Y P; Mishra, P N; Joshi, D D
Keeping in view of high prevalence of tuberculosis in far western development region in different reports, a door to door survey of 125 household was carried out randomly in Mahendra Nagar municipality ward no 13 of Kanchanpur district to pick up symptomatics suggestive of pulmonary tuberculosis and find the prevalence in the target population. A total of 200 sputum specimens from 70 symptomatics within the age range of 10-80 years were collected and subjected to smear microscopy by Ziehl - Neelsen's method. Out of 10 positive cases (14.28%), infection in males and females was 80% and 20% respectively. The infection was found in the productive age group 20-69. The highest prevalence was obtained in 20-29 age group (25%) followed by 40-49 (11%), 30-39 (9%), 50-59 (8%) and 60-69 (8%). The diagnostic yield of single sputum specimen examined was insufficient in field condition, especially where the sputum positivity was low. Of the three sputum smears examined, the early morning specimen had the best result.

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