Organophosphorus compound poisoning: Hoping against hope to reduce morbidity and mortality
Y J Vishewshwara Reddy

APIK Journal of Internal Medicine 2019 7(4):100-102


Biologics: A tectonic shift in the management of rheumatoid arthritis
Ramaswamy Subramanian, Shiva Prasad

APIK Journal of Internal Medicine 2019 7(4):103-108

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints which if ongoing, has a significant bearing in the quality of life and has a variety of systemic manifestation which reduces the overall life span due to an ongoing inflammatory process. There has been a shift in the management of RA right from the early identification of the disease to targeting the pathogenic mechanisms. The changing modalities with emphasis on remission and low disease activity in early RA should be the primary goal. Disease control of RA with the use of combination synthetic disease modifying anti-rheumatic drugs or in combination with biological agents have improved disease-related outcomes. This prevents the progression of disease, morbidity, and has a significant bearing on the overall economic productivity of the patient and the society. Costs of the biological drugs is a major hurdle in their usage. Introduction of biosimilars have lead to a decrease in the cost of the biological molecules and hence their use becoming more widespread. The purpose of this review is to highlight the changing treatment modalities with the advent of biological disease modifiers in RA and a rationale for their use. The strategy in the treatment of RA should be goal directed rather than just relief of symptoms.

Association between serum cholinesterase levels and clinical outcome in patients of organophosphorus compound poisoning – One-year hospital-based longitudinal study
Veerappa Annasaheb Kothiwale, Vivek Veereshkumar Shirol, Viraj V Yerramalla, Vijayakumar G Somannavar

APIK Journal of Internal Medicine 2019 7(4):109-116

Background and Objectives: The activity of serum cholinesterase (SChE) decreases in organophosphate compound poisoning. This study was aimed to evaluate SChE levels as a prognostic marker for patients with organophosphorus (OP) poisoning. Materials and Methods: The present 1-year hospital-based longitudinal study was done on a total of 85 patients admitted with OP compound poisoning in the Department of Medicine, Hospital and Medical Research Centre, from January 2014 to December 2014. The estimation of pseudocholinesterase levels was done at the time of admission, on the 5th day and at the time of discharge. Results: Maximum number of cases had age <30 years (55.29%), and the mean age was 35.28 ± 15.34 years. There was male preponderance with a male to female ratio of 2.4:1. The most commonly consumed compound was malathion (24.71%). Majority of the patients (62.35%) presented after 3–6 h of consumption. The most common symptom was vomiting (87.06%), and peradeniya OP poisoning score revealed moderate intoxication in 58.82% of the patients. SChE levels were profoundly low (≤2500 U/L) in 62.35% of the patients at admission, 65.33% on 5th day, and 62.71% at the time of discharge. Acute renal failure was the most common complication, noted in 23.08% of the patients. Mortality was noted in 15.29% of the patients, and intermediate syndrome was the most common cause (30.77%). Conclusion: There is a positive association of SChE with hospital stay (1st day levels and serial estimation); requirement of ventilatory support (1st day levels); and outcome (serial estimation).

A study of chronic obstructive lung disease among women
Anand Karnam, Indira Ramaiah

APIK Journal of Internal Medicine 2019 7(4):117-119

Background: Chronic obstructive pulmonary disease (COPD) is a preventable cause of globally occurring chronic illness. Although it is known to affect both men and women, there is a prevailing notion that it is essentially an illness of men. Hence, sufficient attention has not been given to COPD among women in our country. We undertook this study in this context. Aims and Objectives: We intended to study the clinical profile of COPD in women and the effect on biomass exposure on lung function. Materials and Methods: A total of 87 women with clinical and lung functional evidence of COPD were included. An enquiry was made to understand the risk factors for COPD. Biomass exposure index was calculated. Results: The severity of illness according to the Global Initiative for Chronic Obstructive Lung Disease staging revealed that 49.4% were in Grade 1 and 2 and 50.5% were in Grades 3 and 4. The duration of symptoms correlated with severity. Most patients were exposed to biomass smoke; the mean biomass index was 136.8 hour-years. The nature of exposure did not appear to influence the severity of illness. Conclusion: Multiple risk factors other than smoking also play a major role in development of COPD. Biomass exposure is a major risk factor in women and duration of exposure correlates with severity of the disease.

A comparative study of concurrent infections of rickettsial infection, Malaria, Typhoid, and Chikungunya with Dengue
Vasantha Kamath, Shreyashi Ganguly, BL Avinash

APIK Journal of Internal Medicine 2019 7(4):120-126

Introduction: In endemic countries such as India, the possibility that acute febrile illnesses are caused due to multiple infectious etiologies is not a rarity. In the postmonsoon season, dengue may often co-exist in the same patient concurrently with other infections such as scrub typhus, chikungunya, malaria, and typhoid. Materials and Methods: This is a prospective observational study aiming to understand the clinical and laboratory parameters and complications of concurrent infections such as typhoid, malaria, rickettsial infection, or chikungunya with dengue. Results: A total of 420 cases of dengue mono-infections were noted. Ninety-two of 512 patients with dengue were co-infected. The most common co-infection was dengue with rickettsiae (48.8%) followed by typhoid (22.2%). Rural, young, males were most affected by co-infections in contrast to mono-infections where rural and urban distribution is similar. The incidence of significant bleed increased in cases of malaria with dengue. Musculoskeletal, gastrointestinal, cardiac, and respiratory complications were seen in increased frequency in co-infections cases. Two deaths were noted in the co-infected groups of rickettsial diseases. Conclusion: The clinical picture and management of co-infected patients differ substantially from patients with mono-infections of dengue. Prompt recognition is necessary to allow the initiation of appropriate intervention in a timely manner. This excludes the possibility of increased morbidity and mortality, which is often avoidable.

Radiological quiz
Fida Hussain Mitha Bhai, Sangram Biradar

APIK Journal of Internal Medicine 2019 7(4):127-127


A case of sentinel headache misdiagnosed: A catastrophe
Fida Hussain Mitha Bhai, Sangram Biradar

APIK Journal of Internal Medicine 2019 7(4):128-130

Headache is the main complaint in outpatients consulting the neurologist and of adult patients presenting to an emergency department (ED) complaining of a headache. About a quarter of all patients presenting to the ED with a sudden-onset severe headache, described as the “worst of their lives,” have a subarachnoid hemorrhage. Patients may report symptoms consistent with a minor hemorrhage such as mild headache before a major rupture, which has been called a sentinel headache. Hereby, we describe a case of warning headache, an underestimated diagnosis.

A rare case of truncus arteriosus in the elderly
Veerapaneni Hareen Choudhary, Sangram Biradar, Iranna S Hirapur, Shiva S Chanda

APIK Journal of Internal Medicine 2019 7(4):131-133

Truncus arteriosus (TA) is a rare cyanotic congenital heart disease, with average survival up to 5 weeks to 6 months. There are factors such as pulmonary arterial hypertension and hypoplasia of the pulmonary branches that are deleterious for life in some cardiovascular diseases. The natural history of the unrepaired defect is not very well known, and is backed by only a handful of such reported cases. We report this very rare case of an uncorrected TA surviving into adulthood and bearing four uneventful childbirths.

Intramedullary spinal tuberculosis in pregnancy: A rare case report
Shridhar Patil, Sangram Biradar

APIK Journal of Internal Medicine 2019 7(4):134-136

Tuberculosis (TB) is an infectious disease which has the pulmonary form as the most common presentation. The spinal column is involved in <1% of all cases of TB. Dissemination of the disease is common in immunocompromised patients, but immunodeficiency related to pregnancy severe enough to cause dissemination of the mycobacteria is rare to date; there has been conflicting evidence on the maternal and neonatal complications of TB in pregnancy. Intramedullary tuberculoma (IMT) is a rare form of spinal TB; spinal TB leading to paraplegia is uncommon in pregnancy and is a diagnostic and therapeutic challenge. Medical therapy is the mainstay of treatment for IMT though there are surgical options for selective patients. We report a case of tubercular paraplegia presenting at 34 weeks of gestation, which lead to paraplegia.