Thrombotic thrombocytopenic purpura in a HIV-positive patient:A hematological emergency

Dear editor,Thrombotic thrombocytopenic purpura(TTP)is an acute non-immune acquired microangiopathic hemolytic anaemia.It is characterized by the classic pentad features of fever,thrombocytopenia,hemolytic anemia,neurological symptoms and renal dysfunction,although all five clinical features are seen in less than 10%of patients[1].The diagnosis of TTP is frequently neglected since thrombocytopenia is a common hematological finding in patients with TTP and human immunodeficiency virus(HIV)infection.The peripheral blood film composed of schistocytes(fragmented red blood cells)plays a crucial role in diagnosing TTP associated with a chronic infection such as HIV.

Ceftazidime resistance in Burkholderia pseudomallei:First report from India

Melioidosis,a disease of public health importance in Southeast Asia and Northern Australia,of late has shown an increasing trend in India,particularly Southern India.We describe a ease of a 39-year-old diabetic patient with left elbow septic arthritis,multiple liver,splenic abscesses, pneumonia,pleural effusion,followed by sepsis syndrome.Blood cultures and culture of the joint aspirate yielded pure growth of Burkholderia psettdomallei(B.pesudomallei),sensitive to carbapenem,co-trimoxazole and resistant to ceftazidime.The patient was successfully treated with imipenem- cilastin.He was discharged on co-trimoxazole to complete the 24 weeks course and follow-up has continued to date.The patient continues to remain asymptomatic.The case re-emphasizes the need to monitor the trend of B.pseudomallei in India,particularly the development of ceftazidime resistance,which incidentally is the drug of choice.

Severe cytomegalovirus infections in immunocompetent patients at admission as dengue mimic:Successful treatment with intravenous ganciclovir

Cytomegalovirus(CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons.The incidence and association of CMV reactivation with adverse clinical outcomes in critically ill persons lacking evidence of immunosuppression at ICU admission has received great attention in the practice of critical care medicine.Critically ill patients in ICU who had associated risk factors such as mechanical ventilation,severe sepsis, or blood transfusion are more prone to CMV activation,which in turn led to increased mortality and morbidity in tenns of increased ICU stay,longer duration of mechanical ventilation,and higher rates of nosocomial infections.However,severe CMV as initial presentation mimicking dengue infection is rare.We recently came across seven cases with positive CMV serology at ICU admission,which we discuss in the light of current literature.

Angiosarcoma of Maxillary Sinus: A Case Report

Purpose: To describe a rare malignancy involving the sinonasal cavities. To discuss the clinical, diagnostic, and treatment modalities. Study Design: A case report including histopathological, radiological analysis and review of literature. Method: A case report is described from a tertiary care centre. Histopathological and radiological details are reviewed. Results: This case report presents a 29 year old male with 3 days history of bleeding from the left nostril, blood stained saliva with post nasal discharge and head ache. Biopsy demonstrated poorly differentiated Angiosarcoma. On immune stains the tumor cells showed diffuse strong cytoplasmic membrane positivity with CD 31 and few cells are positive for CD34. FLI-1 is also positive. Conclusion: Angiosarcoma is a rare malignancy involving the sinonasal cavities. Multidisciplinary approach is essential to obtain clear diagnoses and appropriate treatment plans.

Role of Intratympanic Steroids in the Management of Idiopathic Sudden Sensori Neural Hearing Loss— Our Experience of 67 Cases

Objective: To assess the outcomes of intratympanic steroids in the management of idiopathic sudden sensorineural hearing loss. Study Design: Retrospective study. Setting: Academic tertiary care medical centre. Materials and Methods: A total of 67 patients with idiopathic sudden sensorineural hearing loss were included in our study. Pre- and post-injection audiograms were taken to assess the outcomes in improvement in hearing. Hearing outcomes were assessed with respect to duration of onset of treatment and age of the patient. Improvement in the speech discrimination score was also assessed. Results: A total of 67 patients were included in our study of which unilateral cases were 59 and bilateral cases were 8. Subjectively 35 patients reported improvement in hearing after the therapy while objectively we found 44 ears [41 patients] had improvement. The mean PTA pre ITS was 62.7 and after ITS it was 56.3. Maximum improvement was noted at 2000 Hz and 1000 Hz. Conclusion: Intratympanic steroids can be offered as a first line therapy for idiopathic sudden sensorineural hearing loss as it is minimally invasive, and can be performed as an office based procedure with no systemic side effects. No major complications have been reported in our study and results have been satisfactory.

Role of Intratympanic Steroids in the Management of Meniere’s Disease—A Review of 151 Cases

Objective: To assess the outcomes of hearing and vertigo in patients with Meniere’s disease who were treated with intratympanic methylprednisolone. Study Design: Retrospective study. Setting: Tertiary referral hospital. Methods: In our study with 151 patients [191 ears] were diagnosed as Menieres as per 1995 AAO-HNS guidelines. As an office based procedure these patients were treated with intratympanic methyl prednisolone. Results: There was a 98.6% improvement in the vertigo control rate, a 73.82% improvement in hearing and 29.31% had a definitive improvement in tinnitus. Conclusion: We conclude from our study that intratympanic steroid injection significantly controls vertigo, tinnitus and improves hearing in Meniere’s disease with minimal complications. Hence, it can be tried as a first line treatment for patients with Meniere’s disease.

Osteomyelitis of the Skull Base—A Case Report

Here we report a patient with uncontrolled diabetes, who presented with giddiness and fall due to an episode of seizure. On evaluation with CT and MRI scans, he was found to have pan sinusitis with erosions of the skull base in the floor of sphenoid near lateral recess. PET-CT showed evidence of increased metabolism. He was operated upon by functional endoscopic sinus surgery and debridement of lesion near skull base. The histopathological examination revealed evidence of inflammation with no granulomas or fungal elements or tubercle bacilli. No organisms were grown in microbiological cultures. He started on empirical antibiotics for 3 months and showed improvement. We are reporting this case due to rarity to skull base osteomyelitis.

Epiglottic Schwannoma: A Case Report

Most common site of schwannoma in larynx is aryepiglottic fold and false cords. Epiglottis involvement is rare. The ultimate diagnosis is based on the histologic demonstration of characteristic spindle cells with typical nuclear palisading and positive immunohistochemistry for S-100 protein, but negative for a-smooth muscle actin, CD34, and vimentin. Effective treatment is complete excision.

A New Modality of Treatment for Adult Laryngeal Haemangioma by Coblation: A Case Report

Few adult haemangiomas of larynx have been reported. Most common presentations are in infants where the incidence is about 4% - 5% [1]. In children they resolve by age of five whereas in adults they do not regress. In children the most common modality of treatment is by propranolol. In adults, there are various modalities of surgical excision by laser excision with Co2 or KTP and electrocautery assisted excision. We are presenting a case of adult laryngeal haemangioma that presented with blood-tinged sputum on coughing since 8 months and we managed with micro laryngeal surgical excision by coblation without any complications.

Chronic Sinusitis with Frontal Mucocele: A Case Report

Purpose: To describe a type IIIa frontal mucocele in a case of diffuse nasal polyposis. To discuss the clinical presentation, diagnostic and treatment modalities. Study Design: A case report including radiological, histopathological analysis and review of literature. Methods: A case report from a tertiary care centre. Histopathologic and radiological details are reviewed. Results: This case report presents a 59-year-old male who came to us with fronal headaches and nose blocks of 6 months’ duration. Clinical examination revealed bilateral nasal polyposis. Plain CT scan of paranasal sinuses revealed a circumscribed lesion with erosion of inner table of left frontal sinus amidst pan sinus haziness. We addressed the condition by combined FESS with eyebrow incision frontal craniotomy. Histopathological examination revealed a mucocele. Conclusion: In combined approach, eyebrow incision minimal frontal craniotomy remains the optimal option for visualisation of entire sinus, especially in laterally placed frontal mucoceles;while FESS helps in maintaining physiological drainage and proper follow-up.

Sialendoscopy: A Review of 133 Cases

Objective: The aim is to review the effectiveness of sialendoscopy in treating various salivary gland disorders related to the duct. Methods: A total of 133 patients who underwent sialendoscopy were included in this study. Data was collected from case records of patients and was analysed. A detailed history examination was taken and the operative findings were analysed. Causes of obstructive sialadenitis were evaluated and treated. Results: A total of 159 glands were subjected to sialendoscopy and pathology was identified in 149 glands. Forty one submandibular glands had calculi and twelve had non-calcular obstruction. Fifteen parotid glands had calculi and 81 had non-calcular obstruction, of which stricture was the most common. Calculi retrieval or dilation of stricture was achieved with a sialendoscope in 112 glands. In 23 patients, the calculi were retrieved by combined approach. In three patients, the calculi were fragmented with intra luminal Holmium laser and the fragments were removed. All these patients had a good relief from their symptoms. Duct perforation was seen in two patients and a false passage was formed in one. Conclusion: Sialendoscopy was a safe and effective procedure for managing ductal pathologies of salivary glands.

Correlations between Videostroboscopy and Constant Light Examination with Intraoperative Findings and Histopathology—Our Experience

Objective: To assess the role of stroboscopy in the diagnosis of vocal cord lesions. Study Design: Prospective interventional study. Setting: Academic tertiary care medical centre. Materials and Methods: 50 patients with complaints of hoarseness of voice were clinically evaluated and diagnosis was made using Rigid Videolaryngoscopy, Flexible Videolaryngoscopy and Videostroboscopy. Patients underwent microlaryngeal surgery and a final diagnosis made with histopathological examination. The intra-operative findings and the final histopathological diagnosis were compared with the diagnosis made with rigid, flexible videolaryngoscopy and stroboscopy. Results: Intra-operative findings correlated with stroboscopic findings in 84% of patients, with fibreopticlaryngo-pharyngoscopic diagnosis in 54% of patients and with rigid video-laryngoscopy in 46% of patients. Videostroboscopy showed the highest diagnostic co-relation on histopathology (80%) as compared to rigid videoendoscopy (56%) and flexible videolaryngoscopy (58%). Videostroboscopy also elucidated vocal fold abnormalities that were missed on rigid or flexible laryngoscopic examinations. Conclusion: Videostroboscopy is a valuable complement to a thorough vocal history and physical examination. Videostroboscopy is superior to constant light laryngeal examination in diagnosis of vocal cord lesions.

Tuberculous Otitis Media—A Rare Entity or a Missed Diagnosis

Objective: The aim of the study is to look for indicators of Tuberculous Otitis Media in all cases of chronic suppurative otitis media. Study Design: This is a retrospective study. Setting: This study was conducted in a tertiary care centre. Subjects and Methods: Detected cases of tuberculous otitis media (TBOM) cases studied retrospectively from January 2011 to December 2013 were included in the study. Investigations for tuberculosis were considered in the cases showing suspicious pale granulation tissue in the external auditory canal and middle ear and also in cases showing exuberant pale granulation tissue during mastoid surgery where Zeihl Nielson staining, histopathology, molecular genetic study was done. Cases showing positive result were included in the study. Results: During the study period 751 cases of CSOM were seen in outpatient room of which 18 cases of TBOM were diagnosed. Three patients were diagnosed preoperatively and 181 underwent surgery of which 15 cases were diagnosed positive, from the tissue obtained during the procedure. Direct smear was positive in four cases, concentration techniques in seven cases. Line probe assay was taken as diagnostic in all the cases. None of the cases were positive on histopathology. Conclusion: Tuberculous otitis media is often missed as the classical features are not seen in all cases of TBOM. The absence of these should not stop the clinician from diagnosing the disease. Suspicious tissue should therefore be tested properly to avoid missing the diagnosis and to prevent any complications.

Role of Fibreoptic Endoscopy in Evaluating Swallowing Disorders

Objective: The objective is to assess patients complaining of dysphagia with fibreoptic endoscopic evaluation of swallowing [FEES]. Study design: It is a prospective study. Setting: The study is conducted at Tertiary referral hospital. Methods: In our study, twenty patients with complaints of dysphagia were evaluated with fibreoptic endoscopic evaluation of swallowing. Patients with pharyngeal cause of dysphagia were identified and recommended dietary modifications or positional manoeuvre. Results: A total of twenty patients were evaluated with FEES. Patients were categorised into two groups based on the etiological factor: neurological and non-neurological patients. In eleven of the neurological patients, premature spillage was seen in four patients. Pooling for solids was seen in one patient and for liquids in four patients, pooling for both solids and liquids was seen in six patients, penetration was seen in 1 patient and aspiration in one patient. All these patients were diagnosed to have a pharyngeal cause of dysphagia. In the nine of the non-neurological group, pooling of liquids was seen in four patients, and aspiration was seen in one patient. None of the patients of this group had spillage. One patent had penetration. Five patients had pharyngeal cause of dysphagia. Remaining four patients had normal study. These patients with pharyngeal cause were advised dietary modification or positional manoeuvre or a combination of both. Conclusion: FEES is an effective and valuable tool for evaluating pharyngeal dysphagia, and is helpful in guiding the patients for diet and rehabilitation. It is essential to assess the safety of swallowing in patients to prevent silent aspiration and aspiration pneumonia.

Granular Cell Tumour of Larynx— A Case Report

Granular cell tumors, also called Abrikossoff tumors, are benign, slowly growing neoplasms. They may occur anywhere in the body, but head and neck accounts to 45% - 65% of these cases. The most common site is the tongue. Larynx is relatively an uncommon location for these tumours, accounting for approximately three to 10 per cent of the reported cases. Laryngeal granular cell tumour is extremely rare accounting for only 19 reported cases under the age of 17 years. As many as 10% of patients experience multifocal synchronous or metachronous tumors. We present a rare case report of granular cell tumour of the larynx.

Ipsilateral fractures of the acromion and coracoid processes of the scapula

A fracture of the acromion and coracoid processes of scapula is rarely seen in the outpatient clinic,due to the acromion's anatomical position and shape,as well as the strong ligaments and muscles that are attached to it.These fractures are caused by either direct or indirect high-energy trauma injuries to the shoulder joint,leading to severe pain and a grossly restricted range of motion.Several acromial classifications were reported,but this type of longitudinal plane fracture of the acromion process in our case is yet to be described in the current literature.We present a rare combination of the coracoid process and unstable acromion bony projection fractures that have not previously been noted for this type of fracture.The closest to this is Kuhn's type III classification.A 51-year-old male presented to our emergency department complaining of the right shoulder pain and difficulty raising his arm following a 2-wheeler accident.The patient was managed by open reduction and internal fixation with 3 cannulated cancellous screws fixation and progressed well with no postoperative complications.He was asymptomatic postoperatively and regained full range of motion after 4 months.

Acute paroxysmal cold hemoglobinuria upon dengue fever:A case report

Rationale:Dengue fever is capable of inciting the formation of transient polyclonal antibodies directed at red blood cell antigens,resulting in complement-mediated hemolysis,leading to intravascular hemolysis and hemoglobinuria.Patient’s concern:A 12-year-old male patient who recovered from dengue fever a week ago had red blood cell agglutination,spherocytes,and engulfment of red blood cells(erythrophagocytosis)by monocytes and neutrophils on routine hematological peripheral blood smear.The unexpected blood smear results prompted the lab physicians to investigate autoimmune hemolytic anemia,which revealed a monospecific positive direct antiglobulin test for complement(C3d,C3b)and the presence of Donath-Landsteiner antibody.Diagnosis:Paroxysmal cold hemoglobinuria(PCH),secondary to dengue fever.Interventions:Oxygen supplements,antibiotics,intravenous immunoglobulins,steroid therapy,and packed cell transfusions were administered.Outcomes:The patient’s condition was improved following the therapy.Lessons:Post-dengue PCH is a rare complication that requires a thorough peripheral smear examination for erythrophagocytosis,as advanced hematology analyzers fail to detect such findings.

Glomus tympanicum removal using transcanal endoscopic assisted surgery:An experience with six cases

Objective:To evaluate an endoscopic approach in the management of glomus tumor,and also to investigate and evaluate its appropriateness and feasibility.Methods:Glomus tumors,also known as paragangliomas,are benign primary tumors of the middle ear.The advent of endoscopic ear surgery has provided new dimensions to the management of this highly vascular tumor.Retrospective analysis of six patients of glomus tympanicum,operated between July 2014 and June 2019,with modified Fisch classification Type A and B1,who were managed by a retroauricular transcanal endoscopic approach.Preoperative and postoperative analysis was done for these patients.Results:The chief complaint was pulsatile tinnitus,which disappeared in five cases and reduced in severity in one of them.Hearing was improved with reduction in air‐bone gap in all the cases.No major complications or recurrence were observed in any of the patients after 12 months of follow‐up.Conclusion:This endoscopic approach serves as a safe and reliable technique for tumor removal.It thus provides postoperative comfort for most of the patients.