Publications

BACKGROUND: Electrolyte abnormalities are frequent in systemic infections such as enteric fever but remain under-recognized in clinical practice. These disturbances may worsen morbidity if not identified and corrected early.

OBJECTIVE: To determine the prevalence and pattern of serum electrolyte alterations in adult patients hospitalized with enteric fever at a tertiary care center in New Delhi.

MATERIALS AND METHODS: This retrospective observational study analyzed records of 128 adult patients (59 males, 69 females) with laboratory-confirmed enteric fever between January 2023 and March 2024. The first admission values for sodium, potassium, chloride, and bicarbonate were extracted from the hospital laboratory system. Results were categorized as low, normal, or high using standard clinical reference ranges. Descriptive statistics were applied, and gender-based comparisons were performed using Chi-square tests for categorical variables and t-tests for continuous measures.

RESULTS: Hyponatremia was present in 58.6% (75/128) of patients, while 57.8% (74/128) had low bicarbonate levels consistent with a trend toward metabolic acidosis. In contrast, potassium and chloride values were predominantly normal, with abnormalities occurring in <10% of patients. The mean ± standard deviation (SD) values (mmol/L) were: sodium 132.7 ± 6.2, potassium 4.3 ± 0.6, chloride 101.1 ± 3.7, and bicarbonate 20.3 ± 4.7. No significant gender differences were detected for mean values or abnormality prevalence (all p > 0.17).

CONCLUSION: Hyponatremia and reduced bicarbonate were the most common electrolyte abnormalities in enteric fever, whereas potassium and chloride disturbances were uncommon. Routine electrolyte monitoring should be incorporated into the management of hospitalized enteric fever patients to enable early correction and improved clinical outcomes.

Takotsubo cardiomyopathy, or "broken heart syndrome," is a condition characterized by transient left ventricular dysfunction, typically triggered by intense emotional or physical stress. While initially thought to follow primarily negative life events, such as grief or fear, a subset of cases now recognized as "happy heart syndrome" occur instead after positive emotional triggers, such as celebrations, romantic moments, or good news. This review summarizes the current understanding of takotsubo syndrome (TTS) precipitated by joyful events, focusing on novel insights from the largest registry analysis to date of 37 "happy heart" cases from the international, multicenter GEIST registry. Compared with the more common negative emotional trigger group, these patients had a higher prevalence of men and atypical midventricular ballooning patterns. While event rates trended lower, likely due to the small sample size, acute complications, such as pulmonary edema, and long-term mortality did not definitively differ. The pathophysiology of "happy heart syndrome" remains unclear but implicates differences in central autonomic processing and peripheral catecholamine responses to positive vs negative emotional stimuli. Several key outstanding questions are highlighted, including understanding susceptibility factors, confirming prognostic differences, and leveraging insights into underlying brain-heart circuitry. Ultimately, dedicated research into this rare but fascinating condition could provide broader mechanistic insights and therapeutic opportunities for the prevention and management of all takotsubo phenotypes at the nexus of mind, brain, and heart.

AIM: The thyrotropin controversy in subclinical thyroid disorders (STDs) is among the most common endocrine disorders globally. In India, approximately 42 million people suffer from thyroid disorders, with subclinical hypothyroidism (SCH) affecting about 9.4% of the population. SCH is more prevalent in females (11.4%) compared to males (6.2%).

DISCUSSION: The diagnosis and treatment of SCH and subclinical hyperthyroidism (SHT) are controversial. SCH is often diagnosed based on biochemical markers, as patients may be asymptomatic or exhibit vague symptoms. Thyrotropin (TSH) levels may be elevated or decreased, while triiodothyronine (T3) and thyroxine (T4) remain within the normal reference range or near the lower or upper limits. STDs refers to an abnormal TSH with normal thyroxine (FT4) and free triiodothyronine (FT3) levels. It includes STDs and individuals at high risk for disease progression or adverse outcomes, with unclear prognosis. Progression of SCH to overt hypothyroidism depends on initial serum TSH levels, thyroid peroxidase antibodies (TPO), family history of thyroid disorders, previous radiation, and smoking. Controversies surround SCH and its association with cardiovascular diseases (CVD), pregnancy outcomes, neuropsychiatric issues, metabolic syndrome, dyslipidemia, and diabetes. Assay interference is a problem in interpreting thyroid function tests (TFTs), occurring in 1% of cases. The health package investigation systems often overlooks the impact of drug intake and assay interference. Various methods for measuring TFTs, such as radioimmunoassay, immunometric assay, and ELISA, differ in sensitivity, specificity, and standardization, leading to methodological variability. Common causes of assay interference include human antimurine antibodies (HAMA), thyroid hormone autoantibodies (THAAbs), rheumatoid factor, antistreptavidin, and antiruthenium antibodies. When diagnosing SCH, it is crucial to rule out other causes of elevated TSH, such as autoantibodies, goiter, and rare conditions such as thyroid hormone resistance (THR), diagnosed by serum glycoprotein alpha subunit (α-GSU) and family history. Biotin, a common supplement, can affect TFT assays, leading to spurious results. It can cause falsely high T4 and T3 levels and low TSH, leading to misdiagnosis of SCH.

CONCLUSION AND RECOMMENDATIONS: The timing of TFTs, whether fasting, postprandial, or random, remains a debated issue. Assay interference and biotin intake should be considered when analyzing TFTs. The role of iodine and iodine supplementation during pregnancy and its impact on STDs are not yet fully conceptualized. Large randomized clinical and epidemiological studies are needed to establish a consensus on the diagnostic threshold for TSH. These studies should include diverse populations and medical conditions to improve our understanding of the disease and patient outcomes. In practice, avoid rushing to treat elevated TSH levels between 4 and 10 mIU/L or low TSH between 0.5 and 0.1 mIU/L without confirming the diagnosis with additional tests (T3, T4, FT4, FT3, and TPO). TSH alone should not be the sole decision-maker; consider other TFTs and sequential testing from the same laboratory and time to make more informed decisions. While TSH levels can be affected by time and prandial state, FT3 and FT4 levels remain stable, suggesting all three TFTs may aid in accurate diagnosis and treatment decisions.

INTRODUCTION: Diabetic retinopathy (DR) is a microvascular disorder occurring due to the long-term effects of diabetes mellitus and is the most common cause of severe vision loss in adults. Diabetic retinopathy may lead to vision-threatening damage to the retina, eventually leading to blindness.

AIM: To study the effect of 12 weeks of intensive lifestyle intervention program on diabetic retinopathy using OCT and VEP.

SETTING AND DESIGN: Quasi-experimental study conducted in the Department of Physiology in collaboration with the Department of Ophthalmology at AIIMS, Nagpur.

MATERIALS AND METHODS: 75 patients of type 2 diabetes mellitus with a duration of >5 years were recruited as per the inclusion and exclusion criteria. After taking clinical history and anthropometry parameters, visual evoked potential and optical coherence tomography were done. Then, a 1.5-hour lifestyle intervention session was conducted. Followed by follow-up visits on 15th, 30th, and 45th days, done with biweekly follow-up in between through telephonic/ WhatsApp group.

RESULTS: Modification in dietary pattern, regular exercise, healthy sleep schedule, and stress management showed a reduction in latencies and no major changes in amplitudes, but overall mild improvement was observed in PRVEP and FVEP. Also, in the retinal nerve fiber layer, mild changes along with a reduction in the severity of thickening of the retinal nerve fiber layer (RNFL) of both eyes were seen, but no major changes in central macula thickness were observed.

CONCLUSION: Lifestyle modifications play a crucial role in the improvement of diabetic retinopathy.

BACKGROUND: People living with human immunodeficiency virus (PLHIV) are known to have decreased quality of life (QoL), increased fatigue, and neurocognitive dysfunction. In India, the prevalence and predictors of the same are not explored. We aim to determine the prevalence and predictors of neurocognitive impairment (NCI), fatigue, and health-related QoL among PLHIV in India.

SETTING: The study was conducted among people attending an antiretroviral therapy center in a tertiary care hospital in New Delhi after ethical approval.

MATERIALS AND METHODS: We enrolled consented patients and used the Montreal Cognitive Assessment (MoCA), Multidimensional Assessment of Fatigue (MAF) scale, and 36-item Short Form (SF-36) survey to assess NCI, fatigue, and health-related QoL (HRQoL), respectively.

RESULTS: A total of 100 PLHIV with a mean age of 42.0 ± 9.6 years were enrolled, with 48% females. 47 patients (47%) had NCI with a MoCA score <26. Male gender, PLHIV with <5 years of treatment, and <50 years of age had higher MoCA scores. MoCA scores had a negative correlation with age and MAF scores and a positive correlation with SF-36 scores. 55 patients (55%) suffered from fatigue, with lesser fatigue scores for males. Fatigue scores had a negative correlation with SF-36 scores. 71 patients (71%) had total SF-36 scores >50 with males having higher scores. Fatigue had a negative correlation on QoL, r = -0.831.

CONCLUSION: In India, the prevalence of NCI, fatigue, and decreased QoL is higher compared to other populations. Management strategies in HIV require interventions to improve NCI, fatigue, and QoL along with antiretroviral therapy.

BACKGROUND: Malarial retinopathy refers to a constellation of changes seen in severe or complicated malaria cases. These include: retinal whitening, vessel changes-whitening, tramlining, retinal hemorrhages, and papilledema. There are very few Indian studies on this entity. Since retina can be easily visualized by direct ophthalmoscopy, this study was done to determine prevalence of malarial retinopathy among malaria cases and to determine relationship between malarial retinopathy and severity of the disease.

MATERIALS AND METHODS: The study was done at Indoor and Outdoor Departments of Tropical Medicine, School of Tropical Medicine (STM), Kolkata, with the support of the Department of Ophthalmology, Regional Institute of Ophthalmology (RIO), Medical College, Kolkata. Adult malaria cases, both complicated/severe and uncomplicated, were included. Patients unable or unwilling to cooperate with eye examination, contraindications to tropicamide eye drops (angle closure glaucoma or known allergy to product), severe corneal scarring or cataracts hindering view by ophthalmoscopy, diabetes mellitus, hypertension, intracranial space occupying lesions, epilepsy, alcohol use, chronic renal failure, age > 60 years and any other known ocular/systemic disease that can cause retinopathy changes were excluded. Severe malaria was diagnosed as per the WHO criteria. Cases with acute febrile illness of other causes were taken in control arm, and normal population subjects were taken as controls. All patients were assessed clinically, followed by appropriate laboratory investigations and then direct ophthalmoscopic examination was done. Ocular findings were be collaborated with severity of illness.

RESULTS: A total of 71 malaria cases were included in our study. Among them, 12 cases were of severe malaria, and rest of the cases were uncomplicated. Of the 12 severe malaria cases, 8 were Plasmodium vivax, 3 were Plasmodium falciparum, and 1 was mixed. Uncomplicated malaria cases were mostly P. vivax (35 out of 59). Features suggestive of malarial retinopathy were noted in 9 out of 12 cases of severe malaria (75%) and 2 out of 59 cases of uncomplicated malaria (3.4%). We noted two cases of retinal changes-one case of retinal whitening in falciparum malaria and one case of vivax malaria with retinal hemorrhage in the uncomplicated group. Both of the cases subsequently needed admission for recurrent vomiting, reduced urine output, and severe weakness 40 dengue cases were included in control arm of AFI cases-20 DHF cases and 20 cases of DF with warning signs. Among them, retinal hemorrhage was noted in one case of DHF (2.5%). Out of 40 sepsis cases, retinal hemorrhage was seen in one case (2.5%). No retinal changes were noted among 40 other AFI cases which included scrub typhus, enteric fever, chikungunya, and acute viral hepatitis. Also, no abnormality was detected on ophthalmoscopy in 40 healthy individuals. The presence of retinopathy was suggestive of severe malaria (p < 0.05). We found the sensitivity and specificity of malarial retinopathy as a marker of severe malaria to be 75% and 96.6% with a positive predictive value of 81.8%.

CONCLUSION: Malarial retinopathy may serve as an important clinical biomarker for predicting severe malaria. All clinicians should be appropriately trained in performing direct ophthalmoscopy to detect the retinopathy changes.

BACKGROUND: Pigment nephropathy is an underrecognized cause of acute kidney injury. Data from northern India is scarce. The present study aims to assess the clinical characteristics and outcomes of pigment nephropathy in this region.

MATERIALS AND METHODS: We analyzed the demographics, etiology, and outcomes of 20 patients with biopsy-proven pigment nephropathy.

RESULTS: The mean age was 27.75 years (range: 13-52), with a male-to-female ratio of 18:2. The average peak serum creatinine was 12.09 mg/dL (range: 0.84-22.3). Rhabdomyolysis was identified in 14 (70%) and hemolysis in 6 patients (30%). The rhabdomyolysis was attributed to hypokalemia, infection, strenuous exercise, physical trauma, inflammatory myositis, neuroleptic malignant syndrome, and heat stroke. The hemolysis was caused by paroxysmal nocturnal hemoglobinuria, thrombotic microangiopathy, transfusion reaction, rifampicin, and physical stress. The majority of patients (85%) required hemodialysis, with a mean of 6 sessions (range: 3-17). The mean duration of hospitalization was 15.3 days (range: 4-30), and the average time to renal recovery was 3.1 weeks (range: 2-6). All 20 patients survived and achieved complete renal recovery. Of the 20 patients, 13 completed at least 1 year of follow-up, 4 were lost to follow-up, and 3 remain under observation. At 1 year, all 13 patients had normal serum creatinine. None progressed to chronic kidney disease.

CONCLUSION: Of 20 patients (4.1%) with pigment-induced acute kidney injury (AKI), 70% had myoglobin- and 30% hemoglobin-induced nephropathy. Common causes included hypokalemia, infection, strenuous activity, and paroxysmal nocturnal hemoglobinuria. Hemodialysis was required in 85%, with an average hospital stay of 15.3 days. Among 13 patients with a 1-year follow-up, none developed chronic kidney disease. Overall prognosis appears favorable; however, larger studies with extended follow-up are needed to better characterize long-term outcomes in pigment nephropathy.

Acute myositis and Guillain-Barré syndrome (GBS) occurring together in a single patient is a rare clinical phenomenon that poses both diagnostic and therapeutic challenges. This article discusses the pathophysiology and clinical presentation of these two neuromuscular disorders. The simultaneous occurrence of infectious myositis and GBS is uncommon, and the identification of Enterococcus as the causative agent is even rarer. In this report, we describe a case involving a middle-aged female who presents with both acute infectious myositis and GBS.

INTRODUCTION: Anemia is considered to be a public health issue of serious concern universally. In the current era of advancing technology, electronic health (e-health) initiatives are being employed in various health programs for disease screening and management. This study was planned to screen for anemia and manage it through a multidimensional approach comprising iron folic acid (IFA) supplementation, deworming among children, and dietary guidance and health education through pop-up videos with the aid of e-health initiatives.

METHODS: This was a prospective cohort study. An Android e-application (app) was used on tablets to identify anemia after hemoglobin estimation through the Hemoglobin Color Scale. Accredited Social Health Activists (ASHAs) managed anemia by providing health education and dietary guidance through pop-up videos and IFA supplementation. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 29. Tests of significance in the form of Cochran's Q, McNemar, chi-square, and repeated measures analysis of variance (ANOVA) and independent t-test were applied.

RESULTS: The overall prevalence of anemia significantly declined from 46.08% at baseline to 14.65% at the 9th month. Males had a higher anemia prevalence (52.8%) compared to females (39.16%). An overall improvement of 68.2% was observed in the anemia status, with the maximum being in the 1-5-year age-group and females. Mean hemoglobin levels showed a consistent increase across all age-groups, with the maximum being in the 6-month-1-year age-group and females.

CONCLUSION: This study demonstrated that community-based, sustained, and targeted strategies through the use of e-health initiatives can effectively combat anemia and achieve significant improvements in hemoglobin levels across all age and gender groups.

INTRODUCTION: Low or abnormal plasma concentrations of anti-tuberculosis drugs can be a major reason for treatment failure or the emergence of drug resistance. Acetylator status, which affects drug metabolism, plays a key role in determining drug bioavailability. This study aimed to perform therapeutic drug monitoring (TDM) of rifampicin and isoniazid and to evaluate the correlation between plasma drug concentrations and acetylator status among Indian patients receiving first-line antituberculosis therapy.

METHODS: Plasma concentrations of rifampicin and isoniazid were measured using in-house standardized high-performance liquid chromatography methods, while acetylator status was determined by conventional PCR of NAT2 gene.

RESULTS: Peak concentrations were estimated from 125 patients on first-line tuberculosis (TB) treatment. Among these, 56% exhibited subtherapeutic rifampicin concentrations and 28% had subtherapeutic isoniazid concentrations. Conversely, above normal (potentially toxic) concentrations were seen in 2% and 21% for rifampicin and isoniazid, respectively. Despite receiving the standard TB treatment regimen, only 62% of patients improved clinically, while 38% of patients continued harboring TB signs and symptoms, among which 6 patients (5%) developed rifampicin resistance during the treatment course. About 44% were slow acetylators, followed by 40% intermediate and 16% rapid acetylators. The acetylator status significantly influenced the plasma concentrations of both drugs. Slow acetylators had significantly higher isoniazid concentrations (p = 0.004) and lower rifampicin concentrations (p = 0.01) as compared to rapid acetylators.

CONCLUSION: Abnormal concentrations of rifampicin and isoniazid are prevalent and a major concern. Acetylator status influences plasma concentrations of rifampicin and isoniazid. Hence, determining acetylator status and performing TDM could be instrumental in optimizing and improving TB outcomes.