ISSN - 2394-3637
SMJ
Stanley Medical Journal
VOL 2 | ISSUE 1 | JANUARY - MARCH | 2015
An Official Publication from
Govt. Stanley Medical College, Chennai
WWW.SMJ.ORG.IN
Stanley Medical Journal - Members of the Editorial Board and Advisory Committee
Vol 2 | Issue 1 | January - March | 2015
Stanley Medical Journal
PAtron
Dr. P. Karkuzhali
editor in chief
Dr. P. Seenivasan
Editorial Board
Dr. P. Seenivasan
Dr. S. Vishwanathan
Dr. D. Nagarajan
Dr. Mary Lilly
Dr.Sridhar
Dr. V. Kalaivani
Dr. Rosy Vennila
Dr. R. Selvaraj
Dr. S. Shanthi
Dr. M. Edwin Fernando
Dr. P. Soundararajan
Dr. S. R. Subramaniam
Dr. A.R.Venkateswaran
Dr. K. Kuberan
Dr. R. Jayanthi
Dr. R. Selvi
Dr.K.Chandramouleeswari
Dr. G. Chandrasekar
Dr. K. Balasubramaniam Dr. S. Chitra
Dr. Caroline Priya K
Dr. K. Bhaskar
Students’ Editorial Board
Dr.Sabari Selvam
Dr.V.S.Aadithya Raman
S. Giridharan Ayesha Sanofar R
V.DilipKumar
S.Vignesh Kumar
Skanthavelan Balamani S.Boopathi Raja
T.J.Vanathi T.Emayah
Abinash Rout R.C.Shanjeev Kumar
office bearers 2015-2016
Skanthavelan Balamani S.Boopathi Raja
T.J.Vanathi T.Emayah
Abinash Rout R.C.Shanjeev Kumar
Letter
from the
Patron
The 7th of April marked the world health day, celebrated to commemorate the founding of WHO.
The theme for this year, “From farm to Plate- Make Food Safe!” is highly relevant in the present day
scenario in food industry (yeah, the irony of even food becoming an Industry has been seen in the
modern day).
Food, a Basic Need of all life forms be it the small bacteria or the seemingly mighty us, the “humans”,
is not always available to all – especially to the ones in unfavourable socio-economic conditions! And
Unfortunately Even if available, it’s not always SAFE.
“Doeth no Harm” is the first principle in medicine! Many cultures hold food to be the greatest medicine when used by a wise head. The very food that’s revered so, sometimes hurts the ‘patient’ but the
blame for it should rest not upon the food itself but upon the heads that were involved in handling
it - From Farm to Plate!
The role played by various “heads” involved can never be overstated! From the farmer who produces
to the trader who delivers us the various food products, multiple levels of food handling exist depending upon the kind of food, whether its processed or not, whether its stored frozen or at room
temperature and so on. Thing is it’s necessary to ensure the proper storage at each and every level
so as to deliver safe! With the recent trends of going for processed foods, frozen foods which can be
reheated before use, increased reliance on the fast food and hotel industry, the number of levels involved is ever on the rise and thus the associated risk of contamination of The 7th of April marked the
world health day, celebrated to commemorate the founding of WHO. The theme for this year, “From
farm to Plate- Make Food Safe!” is highly relevant in the present day scenario in food industry (yeah,
the irony of even food becoming an Industry has been seen in the modern day).
Food, a Basic Need of all life forms be it the small bacteria or the seemingly mighty us, the “humans”,
is not always available to all – especially to the ones in unfavourable socio-economic conditions! And
Unfortunately Even if available, it’s not always SAFE.
“Doeth no Harm” is the first principle in medicine! Many cultures hold food to be the greatest medicine when used by a wise head. The very food that’s revered so, sometimes hurts the ‘patient’ but the
Vol 2 | Issue 1 | January - March | 2015
Stanley Medical Journal
Vol 2 | Issue 1 | January - March | 2015
Stanley Medical Journal
blame for it should rest not upon the food itself but upon the heads that were involved in handling
it - From Farm to Plate!
The role played by various “heads” involved can never be overstated! From the farmer who produces
to the trader who delivers us the various food products, multiple levels of food handling exist depending upon the kind of food, whether its processed or not, whether its stored frozen or at room
temperature and so on. Thing is it’s necessary to ensure the proper storage at each and every level
so as to deliver safe! With the recent trends of going for processed foods, frozen foods which can
be reheated before use, increased reliance on the fast food and hotel industry, the number of levels
involved is ever on the rise and thus the associated risk of contamination of food too! So, why does
it really matter? The disease burden produced due to the food borne and waterborne diarrhoeal illnesses alone produced as many as 2 million deaths last year alone.Food borne illnesses can be as
trivial as a diarrhoea or as grave as cancer. The big picture containing the morbidity and mortality
data from 199 other possible diseases, as you can imagine based upon this number, isn’t really nice
one. Unsafe food takes a heavy toll from the already overwhelmed healthcare system that struggles
to even see if there’s an end to the tunnel, let alone seeing if there’s light. This is just touching upon
the practical need for safe food! Then comes the important “humane” part - The Moral Obligation to
ensure Safe Food!
What can be done for safe food? Succinctly put, “Awareness precedes Choice and Choice Precedes
actions.” The best time to have taken the steps would have been a few decades back, but the next
best time, as they say, is right now! The Aim of WHO in this year’s campaign is to create that awareness, with hope that these ripples having a larger effect upon the ocean of health issues that continue
to plague the civilization.
The paradoxical problems of present is, while a proportion of population dies because of lack of food,
a significant also percent also die of excess of it, a problem of QUANTITIES, efforts to prevent which
have failed to bear the fruits of success that they were expected to bear. And people dying from unsafe food, a problem of QUALITY, being entirely avoidable if we take a few basic steps, necessitates
that we do what we can to ensure a better tomorrow.
To leave you, the reader with a few things to contemplate about,
Is it okay to have unsafe food than die of/ suffer from hunger?
Which is the lesser of 2 evils?
What are YOU doing about this problem? Think! And yeah, Feel free to Act too!
Dr. P. Karkuzhali,
Dean,
Stanley Medical College.
Patron , SMJ.
SMJ 2(1);2015
Original Article
01. A STUDY ON NUTRITIONAL STATUS OF SCHOOL
CHILDREN IN RURAL, SEMI URBAN AND URBAN AREAS
OF TAMIL NADU
3
Caroline Priya K, Seenivasan P, Praveen H
Scientific Letter
02. ROLE OF NEPRILYSIN INHIBITORS IN HEART
FAILURE
V.Krishnan, K. Vasanthira
13
Case Reports
01. METASTATIC MALIGNANCIES PRESENTING AS
NODAL ENLARGEMENT
19
Arunalatha1, Srimahalakshmi A
02. PRIMARY MATURE RETROPERITONEAL TERATOMA
INVOLVING THE ADRENAL GLAND
K.Chandramouleeswari , Sujay Surikar
03. DESMOPLASTIC SUPRATENTORIAL NEUROEPITHELIAL TUMOR OF INFANCY WITH DIVERGENT DIFFERENTIATION- A RARE CASE REPORT
23
27
P.Arunalatha, A.Srimahalakshmi, K. Chandramouleeswari, Karthika
04. SECONDARY OMENTAL INFARCTION DUE TO
DUODENAL PERFORATION
Pandiaraja Jayabal, Viswanathan Subramanian
05. FACTITIOUS DISORDER
V.Venkatesh Mathankumar, S.Manikandan, C.Senthil Kumaran, Mohamed Ilyas, R.Saravana
Jothi, T.V.Asokan
06. PSYCHIATRIC MANIFESTATIONS AND NEUROCOGNITIVE PROBLEMS ASSOCIATED WITH HIV
V.Venkatesh Mathankumar, C.Senthil Kumaran, Mohamed Ilyas, R.Saravana Jothi , T.V.Asokan
31
35
37
Vol 2 | Issue 1 | January - March | 2015
Contents
The Grid
-
Emayah Tenzing
Find the 5 sets of 5 interconnected words.
Answer on Page: 12
Gluten
Sensitive
Enteropathy
Mucoviscidosis
Brain Gut Axis
Intestinal
Lipodystrophy
Flushing and
Diarrhoea
Rome Method
Enteropathy
associated T cell
lymphoma
FODMAP
Restrictive
Cardiomyopathy
Argentaffinoma
Meconium Ileus
Visceral
Hypersensitivity
Dermatitis
Herpetiformis
Foamy
Macrophages in
Lamina Propria
PAS positive
big-eaters!
Tissue
Transglutaminase
Hydrogen Breath
Test
Frame shift
mutation
5-HIAA
Octreoscan
Rectal Prolapse
Lymphadenopathy
and Arthritis
Sweat Test
Wheat and
Barley
Impaired
lymphatic
Transport
1
Why do we do basic research? To learn about
Original Articles
ourselves.
RESEARCH IS TO SEE WHAT
EVERYBODY ELSE HAS SEEN, AND
TO THINK WHAT NOBODY ELSE HAS
THOUGHT.
A STUDY ON NUTRITIONAL STATUS OF SCHOOL
CHILDREN IN RURAL, SEMI URBAN AND URBAN AREAS
OF TAMIL NADU.
Caroline Priya K1, Seenivasan P1, Praveen H1
ABSTRACT
BACKGROUND:
The health and nutritional status of children is an index of national investment in the development
of its future manpower. Malnutrition affects the child’s physical and cognitive growth and increases
the susceptibility to infections while having an adverse impact on economic growth of the country
indirectly. With 40% of the world’s malnourished living in India, we face a double jeopardy of
malnutrition. The objective of this study is to evaluate this changing trend and to determine the
burden of malnutrition.
METHODS:
A cross sectional descriptive study was carried out involving 300 children in the age group 11 to 14
years from urban, semi-urban and rural areas.
RESULTS:
67.33% of children were underweight, of which 29.67% were from rural areas; 6% were found to
be overweight or obese, of which 4.67% were from urban areas. There is a significant statistical
difference in the prevalence of underweight children in social class 4&5 as compared to class 1, 2 &
3. The mean calorie consumption of the study population was 1333 kcal which supplies only 50% of
calorie requirement by ICMR standards; the mean calorie intake by children in rural area was much
lower than in urban area.
CONCLUSION:
Our study highlights that children from rural areas and belonging to lower socio-economic classes
are more nutritionally deprived than their counterparts. This difference highlights the necessity of
a differential approach in combating malnutrition.
KEYWORDS:
Malnutrition, rural, calorie consumption.
INTRODUCTION:
3
The health and nutritional status of
children is an index of national investment in
the development of its future manpower.
According to World Health Organization,
protein energy malnutrition refers to
“imbalance between the supply of protein and
energy and the body’s demand for them to
ensure optimal growth and function. This
imbalance includes both inadequate and
excessive energy intake; the former leading to
malnutrition in the form of wasting, stunting
and underweight, and the latter resulting in
overweight and obesity”. The consequences of
child malnutrition are enormous and are
intertwined with the development of society.
1. Govt. Stanley Medical College & Hospital, Chennai
Malnutrition affects the child’s physical and
cognitive growth and increases the
susceptibility to infections and severity of
diseases while having adverse implications on
income and economic growth indirectly.
According to UNICEF data, 90% of developing
world’s undernourished children live in Asia
and Africa while 40% of the world’s
malnourished live in India. The 2013 Global
Hunger Index Report ranked India 16th, which
represents the serious hunger situation. The
National Family Health Survey (NFHS) data
indicates that 43% of children under 5 years of
age are underweight and 2% of them are
overweight. In India, we face a double jeopardy
of malnutrition i.e., children from urban areas
are affected with problems of over-nutrition
while those from rural area suffer from effects
of under-nutrition.
The long term consequences of malnutrition
on a child-turned-adult are issues of deep
concern. Under-nutrition impairs the child’s
immune system and weakens the defences
against other diseases. Whereas over-nutrition
contributes to childhood obesity and leads to
the early onset of hypertension, Diabetes
mellitus, coronary heart diseases, orthopaedic
disorder and other respiratory diseases .
Percentage of
children
Gender
Boys
Girls
Age
11 years
12 years
13 years
14 years
Socio-economic
status*
Class 1
Class 2
Class 3
Class 4
Class 5
55%
45%
39.67%
14.67%
19.33%
26.33%
1.67%
17%
38%
42.67%
0.67%
Table 1. Socio demographic profile
*Modified Kuppusamy’s scale
School age is the active phase of childhood
growth. Poor nutritional status in children
leads to high absenteeism and early school
dropouts thereby affecting the literacy rate of
the country apart from affecting health status
of the children. On the other hand, increasing
lifestyle changes in urban areas has led to the
emergence of over-nutrition and childhood
obesity. To evaluate this changing trend and to
determine the burden of malnutrition, we
carried out a cross sectional study to assess the
nutritional status of school children (11-
14years old). This age group was selected to
highlight the impact and burden of
malnutrition in a population of children turning
into adolescents.
OBJECTIVE:
To determine the nutritional status of
children based on their BMI and waist hip ratio
and its relation to various factors like gender,
area of residence and socio-economic status.
METHODOLOGY:
After being approved by the
Institutional Ethical Committee of Stanley
Medical College, a cross sectional descriptive
study was carried out in the year 2011 over a
period of 3 months from June to September
involving 300 children in the age group of 11 to
14 years. Three schools were selected one
each in rural area, semi urban area and urban
area around Chennai.100 children from each
school were selected as subjects for the study.
Informed consent was obtained from the
principal of the institution and the parents.
Data regarding the subjects’ socioeconomic
background, religion, dwelling place, three day
diet recall and type and duration of physical
activities per day were collected. Also their
anthropometric measurements including
height, weight, circumference of waist and hip
were recorded. We have recorded body weight
to the nearest 0.1 kg using a standard balance
scale with subjects barefoot. Height of the
children from the floor to the highest point on
the head was recorded when the subject was
facing directly ahead, barefoot, feet together,
arms by the sides. Heels, buttocks and upper
back were made to be in contact with the wall
when the measurement was made. The height
was recorded and rounded off to the nearest 1
cm. BMI (weight in kilograms divided by the
square of the height in metres) of the children
were calculated and classified according to
CDC growth charts: United States. The waist
circumference was measured at the level of
umbilicus. The hip circumference was
measured at the widest part of the buttocks.
Waist hip ratios were calculated. Data was
analysed at the end of 3 months with the help
of Epi Info software and Microsoft Excel.
4
Table 2. Relation between BMI, Waist Hip Ratio and Area of residence
*BMI- CDC Growth Charts: United States
Underweight
(based on BMI)*
No
Overweight
(based on BMI)*
No
Waist Hip Ratio
Rural area
Urban area
80
68
89
48
38.9526
11
52
1
14
<0.001
12.1802
99
86
<0.001
20
32
3.7422
Yes
Yes
High Risk
Chi square
P value
=0.053
Low Risk
RESULTS:
Based on the statistical analysis done
at the end of the data collection, the following
results were obtained. On assessing the 300
children for BMI, 67.33% were found to be
underweight, of which 29.67% were from rural
area; 6% were found to be overweight or
obese, of which 4.67% were from urban area.
The percentage of under-weight children was
65% in semi urban area and 48% in urban area
in contrast to 89% in rural area.
Of the 100 children assessed in rural area, only
one was found to be overweight and none was
obese. Among the 100 children assessed in the
semi urban area, 3 were overweight. Whereas
in urban area, 7 children of the 100 were
overweight and another 7 were found to be
obese. Thus, in urban area, almost 14% of the
children were either obese or overweight. This
percentage is significantly higher than the 1%
and 3% found in rural and semi urban areas.
The percentage of the children who were
categorized as normal according to their BMI
was only 10% in rural but 32% and 38% in semiurban and urban areas respectively (Figure 1).
According to the data obtained, waist hip ratio
of the children was also calculated. It is found
that 20% of children in rural area and 32% of
children in urban area fall under high-risk
category of waist hip ratio. Waist Hip ratio
more than 1 in boys and 0.85 in girls indicates
an increased risk of metabolic complications.
Though the frequency of high risk W: H ratio is
higher among children from urban areas than
that of rural areas, the difference was not
statistically significant.
Table 3.Factors associated with BMI
Underweight
Gender
Yes
No
Male
114
51
0.5149
Female
88
47
0.473
110
20
31.1510
92
78
Socioeconomic status Class 4& 5
<0.001
Class 1,2 & 3
5
Chi square
P value
100
90
Number of Children
80
70
60
50
40
30
20
10
0
Underweight
Normal
Overweight
Obese
Rural
89
10
1
0
Semi-urban
65
32
3
0
Urban
48
38
7
7
Fig. 1 Difference in prevalence of under nutrition in regards to area of residence
The prevalence of underweight was 69.09%
among boys and 65.19% among girls. This
difference is not statistically significant
indicating that there is no evidence of gender
inequality in this study (Table 2).
Socio-economic status of each child was
assessed based on modified Kuppusamy’s
scale. The prevalence of underweight children
was 84.62% among socio-economic status
class 4&5 and only 54.12% among socioeconomic status class 1, 2& 3. It is evident that
there is a significant statistical difference in the
prevalence of underweight children in Class
4&5 as compared to Class 1, 2 & 3 ( Table 3).
The children were also asked about their
choice of games and sports. And it was found
that nearly 45% of the boys and girls in rural
area were involved in games requiring severe
physical activity. The mean playtime of
children from rural area was 1.6 hours/day. In
semi-urban area, only 25% of the boys and girls
were involved in games requiring severe
physical activity whereas the percentage was
only around 15% in urban area. The mean
playtime of children from semi-urban and
urban areas were1.6 hours/day and 1.1
hours/day respectively.
The three day diet history obtained from the
children was analysed and the average amount
of calorie intake per day was calculated for all.
The mean calorie consumption of the children,
irrespective of their area of residence, was
1333 kcal. The mean calorie intake of children
in rural area was found to be 991.7 kcal. The
calorie consumption was found to be lesser
when compared to the mean calorie intake in
semi urban and rural areas, which were 1461.7
kcal and 1545.7 kcal respectively (Figure 3). It
was also found that the irregularity in taking
meals was the greatest among the children in
urban area.
6
Fig. 2 Nutritional status of children among various classes of socio-economic status.
DISCUSSION:
A healthy child becomes a healthy
adult. Of the various factors which determine
the health of the child, nutrition plays the most
vital role. Low body weight is unhealthy and
harmful in the way it has dire consequences on
both physical and psychological well-being of a
child. Decreased level of thinking, impaired
concentration, irritable mood and heightened
obsessiveness, while contributing to the
psychological
effects of malnutrition,
undermines the academic performance of a
child and leads to the development of a socially
withdrawn child. On the other hand,
malnutrition has a profound impact on
immune system by weakening the defences
and aggravating the effects of infections.
Infections contribute to malnutrition by a
variety of mechanisms including anorexia and
impaired absorption of nutrients. This shows
that enteric infection begets malnutrition and
malnutrition begets more infections6.
7
According to World Bank statistics, Child
malnutrition is responsible for 22 percent of
India’s burden of disease3and contributes to
an estimated adult productivity loss of 1.4% of
gross domestic product (GDP). It has been
estimated to play a role in about half of all child
deaths and more than half of child deaths from
major diseases, such as malaria, diarrhoea,
measles and pneumonia. Recent trends in
India suggest that there has been a dramatic
fall of severe underweight prevalence in urban
areas (by 26%) compared to rural areas though
the decline in underweight prevalence was
considered inadequate according to UNICEF.
Our cross-sectional study shows that boys are
more likely to be stunted and underweight
than girls though there was no significant
gender inequality because of limited sample
size. Our study determined the association of
underweight children in relation to various
factors like gender, age, area of residence and
socio economic status while data from various
studies indicated that decline in the prevalence
of under-nutrition was lesser in girls compared
Calorie intake
>2000 kcal
1500-2000 kcal
Urban
Semi-urban
1000-1500 kcal
Rural
<1000 kcal
0
10
20
30
40
50
60
Number of children
Fig. 3 Comparison of variations in calorie intake in urban, semi-urban and rural areas
to boys and lesser in scheduled caste &
scheduled tribe as compared to other castes3.
Children with normal BMI constitute only 10%
in rural areas while 38% of them had normal
BMI in urban area. Studies have shown that
mean height and weight of boys and girls was
lower than the CDC 2000 standards in all age
groups. The prevalence of underweight and
stunting was highest among the age group of
11 to 13 years with higher prevalence of under
nutrition in girls. In our study, the mean BMI of
children in rural area was 15.85 whereas
children in urban area had a mean BMI of
20.11. Children with high risk of developing
metabolic complications were relatively higher
in urban area compared to rural area. The
collected data signify that under-nutrition is
the burning problem in rural areas whereas
urban areas suffer from the double jeopardy of
malnutrition. This difference also highlights the
necessity of difference in approach to tackle
malnutrition by ICDS in varying parts of India as
suggested by UNICEF.
Our study illustrates that the probability of a
child being undernourished is nearly 1.6 times
higher in poorer quintile compared to richer
quintile supporting the relation between
malnutrition and socio economic status. The
determinants of the study comprised mainly of
father’s occupation and income rather than
the educational and occupational status of
mother in a patriarchal society like India
.Estimated calorie requirement of an active
child aged 11-14 years is 2190 kcal to 2750 kcal.
However, our study estimated that mean
calorie consumption of the children,
irrespective of their area of residence, was
1333 kcal which supplies only 50% of calorie
requirement by ICMR standards. Also, the
mean calorie intake by children was much
lower in rural area than urban area with semiurban area representing a transitional zone.
This trend makes it clear that varying areas of
residence are associated with varying degrees
of malnutrition which could be attributable to
a spectrum of factors like occupation,
educational status, food fads, superstitious
beliefs, lack of awareness, etc., the
investigations of which is beyond the scope of
this study. Decreasing physical activity and
increasing indoor video games among children
in urban area predispose to the development
of childhood obesity with dire consequences.
Evidences suggest that cell mediated immunity
is depressed in malnutrition thereby increasing
the duration and severity of infections2, .Also,
stunting was found to be significantly
associated with and poly-parasitism, especially
8
Ascaris lumbricoides and Trichuris trichura
contributing to the vicious cycle of
malnutrition. Infant feeding practices and
mother’s education status form the major
determinants of Protein Energy Malnutrition.
Better feeding practices were found to reduce
the prevalence of stunting by 30%. Exclusive
breastfeeding and partial breastfeeding were
found to be more protective when compared
to no breastfeeding. The median relative risk of
death from diarrhoea fell from 25 in no
breastfeeding to 8.6 in exclusive or partial
breastfeeding highlighting the paramount
importance of breastfeeding in the prevention
of malnutrition.
Hence, it is necessary to cut down the causal
factors of malnutrition before the child attains
the age of 3 years. Better feeding practices,
health awareness, sanitation, sustained
availability of nutritious foods for all sections of
people and enhanced access to healthcare
services are essential steps to attain the
Millennium Development Goals by 2015.
Failure to invest in combating nutrition can
have adverse impacts on potential economic
growth. Integrated Child Development
Services (ICDS) Scheme, launched on 2nd
October 1975, is India’s unique programme to
improve the nutritional status of children by
providing supplementary nutrition, pre-school
education, immunization and health education
for pregnant and nursing mothers. Though
ICDS is successful in many ways, decline in
under-nutrition in India is slower when
compared with other developing countries
because ICDS Scheme mainly focusses on food
supplementation rather than health education
and on children aged 3-6 years rather than
younger children (0-3 years). Our study
reiterates the trends of malnutrition in relation
to various factors2, 3, 14, 15 and also highlights
the need for differential approach in urban and
rural areas to combat malnutrition.
Conclusion:
This cross-sectional study was undertaken to
study the nutritional status of children aged
11-14 years and its relation to various factors
like gender, area of residence and socioeconomic status. This study also investigated
the data on the amount of calories consumed
per day, frequency and regularity of taking
meals and level of physical activity in rural,
semi-urban and urban areas.
According to our study, nearly 89% of children
were undernourished in rural area while half of
the children were spared in urban area with no
significant gender inequality. Children
belonging to socio-economic status Class 4&5,
according to modified Kuppusamy’s scale,
were more deprived of nutrients than the
children of upper and middle class. Our study
also estimated that a child from rural area
consumes an average of 991.7 kcal while
calorie consumption of a child from urban area
is much higher, averaging to 1545.7 kcal.
However, the mean playtime of children in
urban area was 1.1 hours/day with most of the
children opting to play video games in their
playtime whereas the mean playtime of a child
was 1.6 hours/day in rural area. This data
highlights a relative increase in calorie
consumption in urban area with increase in
sedentary lifestyle thereby setting a stage for
the development of childhood obesity.
We conclude our study re-emphasizing the
various determinants of malnutrition and
highlighting the changing trend in the
nutritional status of children in urban, semiurban and rural area. More attention on
educating parents to improve nutrition in rural
areas, lifestyle modifications in urban areas
and preferential target on lower socio
economic class can bring about changes in the
issue of malnutrition in India.
CONFLICT OF INTEREST:
9
Dr. Seenivasan. P and Dr. Caroline Priya .K, although are members of Editorial Board, did not
participate in the review of this article which was done by an independent and autonomous panel.
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Moore, Mônica OB Oriá and Aldo AM Lima Malnutrition as an enteric infectious disease
with long-term effects on child development:
Nutrition ReviewsVolume 66, Issue 9, pages
487–505, September 2008.
6. William H. Dietz - Health Consequences of
Obesity in Youth: Childhood Predictors of Adult
Disease: PEDIATRICS Vol 101.No. Supplement 2
March 1, 1998 pp.518-525
7. Park’s textbook of preventive and social
medicine 21st edition.
8. Cognitive Behaviour Therapy and Eating
disorder: Guilford Press, New York 2008
9. Peter Katona and JuditKatona-Apte - The
Interaction between Nutrition and Infection:
Clin Infect Dis. (2008) 46 (10):1582-1588.
10. UNICEF Data: Monitoring the situation of
children and women
11. Shahabuddin AKM, et al.: Adolescent
nutrition in a rural community in Bangladesh.
Indian J Pediatr 2000, 67(2):93-98; Partnership
for Child Development: The anthropometric
status of school children in five countries in the
14. Urke HB, Bull T, Mittelmark MBSocioeconomic status and chronic child
malnutrition: Wealth and maternal education
matter more in the Peruvian Andes than
nationally.Nutr Res. 2011 Oct;31(10):741-7
15. Deshmukh PR, Sinha N, Dongre AR.-Social
determinants of stunting in rural area of
Wardha, Central India :Med J Armed Forces
India. 2013 Jul;69(3):213-7.
16. ICMR(2010), Nutritional requirement and
recommended dietary allowances for Indians,
A Report of the Expert Group of ICMR.
17. Andrew tomkins -Nutritional status and
severity of diarrhoea among pre-school
children in rural nigeria: THE LANCET Volume
317, Issue 8225, 18 April 1981, Pages 860–862
18. Saldiva SR1, Silveira AS, Philippi ST, Torres
DM, Mangini AC, Dias RM, da Silva RM, Buratini
MN, Massad E. - Ascaris-Trichuris association
and malnutrition in Brazilian children:
PaediatrPerinatEpidemiol. 1999 Jan;13(1):8998.
19. L.S.STEPHENSON, M.C.LATHAM and
E.A.OTTESEN - Malnutrition and parasitic
helminth infections : Parasitology / Volume
121 / Supplement S1 / October 2000, pp S23S38
21. Lance Brennan, John McDonald, Ralph
Shlomowitz - Infant feeding practices and
10
chronic child malnutrition in the Indian states
of Karnataka and Uttar Pradesh : Economics &
Human BiologyVolume 2, Issue 1, March 2004,
Pages 139–158
22. R. G. Feachem and M. A. Koblinsky Interventions for the control of diarrhoeal
diseases among young children: promotion of
breast-feeding: Bull World Health Organ. 1984;
62(2): 271–291.
24. World Bank India: Chapter 2 the integrated
child development Services program (ICDS) –
are results meeting Expectations?
23. ICDS Programme and Services.
http://www.wcdorissa.gov.in/download/Final
-1.0-f.pdf
11
The Grid - Answers
-
1.
Emayah Tenzing
4.
5.
Brain Gut Axis
Intestinal
Lipodystrophy
Flushing and
Diarrhoea
Rome Method
Enteropathy
associated T cell
lymphoma
FODMAP
Restrictive
Cardiomyopathy
Argentaffinoma
Meconium Ileus
Visceral
Hypersensitivity
Dermatitis
Herpetiformis
Foamy
Macrophages in
Lamina Propria
PAS Positive Bigeaters!
Tissue
Transglutaminase
Hydrogen Breath
Test
Frame shift
mutation
5-HIAA
Octreoscan
Rectal Prolapse
Lymphadenopathy
and Arthritis
Sweat Test
Wheat and Barley
Gluten Sensitive
Enteropathy
Impaired
lymphatic
Transport
2.
3.
Mucoviscidosis
1. Celiac Disease
2. Cystic Fibrosis
3. Irritable Bowel Syndrome
4. Whipple Disease
5. Carcinoid Syndrome
12
ROLE OF NEPRILYSIN INHIBITORS IN HEART
FAILURE
V.Krishnan1, K. Vasanthira2
ABSTRACT
Despite the availability of many rationally designed drugs , Heart failure ( HF) continues to be a
major cause of morbidity and mortality .Invention of Angiotensin Converting Enzyme inhibitor
(ACEI) is one the cornerstone of heart failure management .ACEI’s are able to prevent the
worsening of cardiac failure by preventing myocyte apoptosis and myocardial remodelling . There
is still an unmet need and search of potentiating endogenous compounds to facilitate cardiac
function throws light on Neprilysin. Combined angiotensin and Neprilysin inhibitor is expected to
create a greater impact in the treatment of heart failure.
Keywords
ACE inhibitors , Heart failure , Neprilysin inhibitors
13
Heart Failure:
Meeting the unmet need:
More than 20 million people suffering
from heart failure worldwide .Incidence of
heart failure in developed countries is 2% and
approaches 6-10 % in people aged more than
65 years. Heart failure and its management
needs considerable attention because of its
prevalence and increased survival of patients
undergoing heart surgery or with previous
history infarction or arrhythmias than the past.
Rheumatic fever still a major cause of heart
failure in Asian and African countries .In the
developed
and
developing
nations,
Hypertension remains the most significant
contributor for heart failure along with
dyslipidaemia, diabetes and ischemic heart
disease [7]. From symptomatic management
by diuretics and oral inotropic agent digoxin,
the advent of ACEI causes transition in
treatment aspect of heart failure. The two
distinct advantages of ACEI are good safety
margin and ability to reverse the myocardial
remodelling is the main reason for selecting
them as first line management of heart failure
even in asymptomatic high cardiovascular risk
patients. Following ACEI, angiotensin receptor
blockers (ARB’s), cardio selective beta blockers
and aldosterone antagonist plays additive role
in preventing myocyte damage.
Even these days, prognosis of
symptomatic heart failure is not promising, 3040 % of patients die within a year and more
than 60 % of patients die within five years of
diagnosis. To meet the unmet, researchers
have started addressing the cause myocardial
injury due to oxidative stress, up regulation of
vasoconstrictors molecules in endothelium has
been done in recent years. Statins role in
improving endothelial function is underway
and endothelin antagonist also appears to be
promising in heart failure. One of the
successful approach was isolating and
formulating the endogenous compound
natriuretic peptide.
1. Saveetha Medical College, Chennai
2. Govt. Stanley Medical College, Chennai
Role of natriuretic peptie and neprilysin
pathophysiology of heart failure:
Natriuretic peptides are produced from
atrium, brain and named as atrial natriuretic
peptide( ANP) and brain natriuretic peptide
(BNP) respectively , in addition to c- type
natriuretic peptide (CNP) .These peptides
exert their action by binding natriuretic
peptides receptors and activate guanyl cyclase
and produces vasodilation . Brain Natriuretic
peptide is produced by any factors that
stretches atria and its plasma concentration is
used as diagnostic tool in assessment of heart
failure. Recently, the recombinant form brain
natriuretic peptide, Nesiritide is indicated for
acute severe heart failure and given as
intravenous bolus infusion at the rate of 0.010.03microg/kg/minute.
Apart from vasodilation , pleiotropic effects of
natriuretic peptide’s includes dieresis ,
decreased sympathetic activation and
inhibition rennin angiotensin system ,
decreases mesangial cell proliferation ,
attenuation of endothelins , control of and
smooth muscle cells and fibroblast
proliferation in the vessels [8.9].
Neprilysin is a metalloproteinase enzyme. It
degrades many vasoactive and other peptides
like
natriuretic
peptides,
bradykinin,
angiotensin etc. This was targeted and found
to be rational that inhibition of Neprilysin will
result in accumulation of endogenous peptides
and results in pronounced diuresis, more
vasodilation, attenuation of rennin angiotensin
activation and fall in blood pressure [10, 11, 12,
13, 14].
Neprilysin and angiotensin converting
Enzyme inhibitors
The combined Neprilysin and
angiotensin converting enzyme inhibitors are
known as vasopeptidase inhibitors .Two
molecules , namely samapatrilat and
omapratilat came into existence of which
omapratilat undergone many clinical trials for
its efficacy and safety .Large trial involving
nearly 25000 patients was done with
omapatrilat
known
as
Omapratilat
cardiovascular treatment versus enalapril (
OCTAVE ) , 24 weeks , randomized , active
controlled study .Omapratilat was started
with 10 mg and increased to 80 mg OD ,
similarly enalapril was 5 mg d and titrated to 40
mg d. Blood pressure reduction with
omapratilat was non inferior to enalapril.
Angioedema was the most the striking adverse
effect seen with omapratilat, from the OCTAVE
it was concluded 274 patients develop
14
angioedema in omapratilat group and 86
patients in enalapril group in 2000 , sponsors
Bristol Meyer Squibb withdrew their new drug
application ( NDA ) from Food and drug
administration (FDA) , United states. In
another study namely (CV 137037), 10 week
active controlled study of omapratilat 40 mg d
and lisinopril 10 mg d, the efficacy of
omapratilat was proved without antecedent
angioedema [5].
These combined angiotensin converting
enzyme inhibitor, also known as vasopeptidase
inhibitors or super ACE inhibitors due to
synergistic inhibitors of endogenous peptides.
Reason for angioedema is sought to be
increased level of bradykinin and angiotensin
by omapratilat. Bradykinin levels were
increased more than 10 fold on patients
developed angioedema following treatment
with omapratilat. This adverse event was
found to be more dose dependent. Incidence
of angioedema is a recognised complication of
ACEI is very less, but escalates when it is
combined with Neprilysin inhibitors [5].
The expected other beneficial actions are
Omapratilat are decreasing the proteinuria in
chronic kidney disease, anti anginal effects and
reducing left ventricular hypertrophy. Though
omapratilat was considered as magic bullet in
the cardiac failure treatment, the adverse
effects were unsolved and FDA announced to
stop further clinical trials with omapratilat.
Nevertheless, it was just hibernation not the
end of Neprilysin inhibitors.
Reborn of neprilysin inhibitors:
15
Angiotensin
converting enzyme
inhibitors producing angioedema due to
inhibiton of bradykinin metabolism is
superceded by angiotensin receptor blockers (
ARB’s) . The same approach has been utilised
to re introduce neprilysin inhibitors with
angiotensin receptors blockers . The
combination is known as Angiotensin receptor
neprilysin inhibitors ( ANRI’s) . LCZ696 is the
first angiotensin neprilsyin inhibitor , this
molecule comprises of angiotensin receptor
blocker valsartan and neprilysin inhibitor
AHU377.This molecule successive passed pre
clinical studies , very effective in various animal
model of hypertension like stroke prone rats ,
spontaneous hypertensive rats model etc .
Pharmacokinetic analysis of angiotensin
receptor nerrilysin inhibitors in humans
showed their maximum plasma concentration
achieved in 1.6-4h[2] .
Clinical trails with ARNI’s
A significant trial was done in heart
failure patients with preserved ejection
fraction known as PARAMOUNT in which 371
patients were enrolled and randomized to
receive either valsartan alone or LCZ696 .
Study concludes LCZ696 showed greater
reduction in blood pressure than valsartan
group.The drug was well tolerated with single
case of angioedema . LCZ696 is undergoing
extensive clinical trial by Novartis namely
Impact on Global Mortality and morbidity in
Heart Failure trial (PARADIGM-HF)in which
LCZ696 is compared with angiotensin
converting enzyme inhibitor , enalapril .
Incidence of heart failure , frequency of
hopsitalisation , incidence of atrial fibrillation
are being analyzed .This phase III multi centric
trials now comprises of more than ten
thousand patients evaluated for endpoints
mentioned above . Another studied is also
planned to compare LCZ696 with an
angiotension receptor blocker in heart failure
patiens namely PARAGON-HF [1]. The
anticipated action of antiprotenuirc effects
from animal models is also examined in UKHARPIIII trial in which LCZ696 and irbesartan is
compared in 360 chronic kidney disease
patients .Results are yet to be known to find its
efficacy in those patients.
Conclusion:
Angiotensin Neprilysin inhibitors are
showing their efficacy in reducing worsening of
heart failure, number of hospitalisation due to
heart failure .Overall long term efficacy and
safety is yet to be studied in detail. Success of
this group of drugs may be more beneficial for
heart failure management.
REFERENCES:
1.
John J.V. McMurray, M.D., Milton
Packer, M.D., Akshay S. Desai, M.D., M.P.H.,
Jianjian Gong, Ph.D., Martin P. Lefkowitz,
Angiotensin–Neprilysin Inhibition versus
Enalapril in Heart Failure N Engl J Med 2014;
371:993-1004
2.
Mariell Jessup, M.D., Keith A.A. Fox,
M.B., Ch.B., Michel Komajda, M.D., John J.V.
McMurray, M.D., and Milton Packer,
M.D.PARADIGM-HF
—
The
Experts'
DiscussionN Engl J Med 2014; 371:e15
3.
Cruden NL, Fox KA, Ludlam CA,
Johnston
NR,
Newby
DE.
Neutral
endopeptidase inhibition augments vascular
actions of bradykinin in patients treated with
angiotensin-converting enzyme inhibition.
Hypertension 2004;44:913-18
4.
Rademaker MT, Charles CJ, Espiner EA,
Nicholls MG, Richards AM, Kosoglou T. Neutral
endopeptidase inhibition: augmented atrial
and brain natriuretic peptide, haemodynamic
and natriuretic responses in ovine heart
failure. Clin Sci (Lond) 1996;91:283-91
5.
Omaprtilat briefing book .FDA advisory
report
[internet
]
Available
as
http://www.fda.gov/ohrms/dockets/ac/02/bri
efing/3877B2_01_BristolMeyersSquibb.pdf
6.
Packer, M., Califf, R.M., Konstam,
M.A., et al. , for the OVERTURE study group.
Comparison of omapatrilat and enalapril in
patients with chronic heart failure. The
Omapatrilat Versus Enalapril Trial of Utility in
Reducing Events (OVERTURE). Circulation,
2002, 106:920–926
7.
Gaziano T, Gaziano JM: Global burden
of cardiovascular disease, in Heart Disease: A
Textbook of Cardiovascular Medicine, 9th ed, E
Braunwald (ed). Philadelphia, Elsevier
Saunders, 2009
8.
Wilkinson IB, McEniery CM, Bongaerts
KH, MacCallum H, Webb DJ, Cockcroft JR.
Adrenomedullin (ADM) in the human forearm
vascular bed: effect of neutral endopeptidase
inhibition
and
comparison
with
proadrenomedullin NH2-terminal 20 peptide
(PAMP). Br J Clin Pharmacol 2001;52:159-64
9.
Maric C, Zheng W, Walther T.
Interactions between angiotensin ll and atrial
natriuretic
peptide
in
renomedullary
interstitial cells: the role of neutral
endopeptidase.
Nephron
Physiol
2006;103:149-156
10.
Kuhn M. Molecular physiology of
natriuretic peptide signalling. Basic Res
Cardiol2004;99:76-82
11.
Anssen WM, de Zeeuw D, van der Hem
GK, de Jong PE. Antihypertensive effect of a 5‐
day infusion of atrial natriuretic factor in
humans. Hypertension 1989; 13:640–46
12.
Burnett JC Jr, Kao PC, Hu DC et al. A
trial natriuretic peptide elevation in congestive
heart failure in the human. Science 1986; 231:
1145–47
13.
Webb DJ. Endogenous endothelin
generation maintains vascular tone in humans.
J Hum Hypertension 1995; 9: 459–63
14.
Pham I, Gonzalez W, el Amrani AI et al.
Effects of converting enzyme inhibitor and
neutral endopeptidase inhibitor on blood
pressure and renal function in experimental
hypertension. J Pharmacol Exp Ther 1993; 265:
1339–47
16
Vol 2 | Issue 1 | January - March | 2015
Stanley Medical Journal
Case Reports
FOR MOST DIAGNOSES ALL THAT IS
NEEDED IS AN OUNCE OF KNOWLEDGE, AN
OUNCE OF INTELLIGENCE, AND A POUND OF
THOROUGHNESS
METASTATIC MALIGNANCIES PRESENTING AS NODAL
ENLARGEMENT
Arunalatha1, Srimahalakshmi A1
ABSTRACT
Metastatic malignancy is a more common etiology of peripheral lymphadenopathy than
lymphoma, especially in patients over 40 years of age. FNAC has proved to be a valuable tool in
diagnosing .These are diagnosed based on the presence of abnormal non lymphoid cells among
normal reactive lymphoid cells .Some of the malignancies have been reported in our department
by FNAC of nodes(inguinal ,cervical).Squamous cell carcinoma is the most common primary tumour
metastasing to the lymph nodes. Cervical lymph nodes are the most commonly involved and the
commonest primary site is head and neck .Here We report one case of elderly man with melanoma
-anal canal; another man with carcinoma penis presenting with inguinal nodal metastasis and a case
of elderly man with hypopharyngeal growth presenting with cervical node .The importance of
presenting this article is mainly to highlight the fact that diagnosing malignancy in lymph node by
FNAC helps in evaluating an unknown primary.
Key words:
FNAC, Lymph Node , Metastasis
Introduction:
Lymph nodes are common site of
metastases for different cancers. Thus clinical
recognition and urgent diagnosis of palpable
lymphadenopathy is of paramount importance
specially
to
differentiate
between
inflammatory lesions or metastatic or primary
neoplastic tumor.
19
Although open biopsy with histological
examination of excised tissue still remains the
golden standard for diagnosis of lymph node
tumors, yet FNAC (Fine needle aspiration
cytology) has now become an integral part of
gained wide acceptance since it offers a high
degree of accuracy, lending itself to out
patients diagnosis and thus reducing the cost
of hospitalization. The results of FNAC
compare favourably with those of tissue
biopsies and in some situations the aspirate
has qualities of a micro biopsy. Suspicious or
doubtful situations should be resolved by
surgical
biopsy
and
further
by
immunocytochemistry
and
molecular
techniques whenever required.3,4 The aim of
the present study is to highlight the role of
FNAC in diagnosis of metastatic lesions of
lymph nodes in a resource challenged
environment like ours.
1. Govt. Stanley Medical College & Hospital, Chennai
A stepwise approach to the investigation of
nodal metastasis is suggested. This includes
patients age and sex ,anatomical site of the
lymphnode,
tumor
cytomorphology,
cytochemical stains and immunoprofile. The
cytological patterns seen in routinely stained
smears often gives clues to the site of the
primary tumour.
Case report:
Patient 1: Rajendran 40/M with the c/o
dysphagia for two years and swelling in the
right cervical region (lymph node) for the past
two months. FNAC done in cervical node
showed the picture in figure 1.
Fig. 1 showing the metastatic squamous cell
carcinomatous deposits in the right cervical
node. LOW POWER VIEW:
HIGH POWER VIEW:
PATIENT 3: Babu 60/M present with B/L
inguinal lymph nodes. Right sided node
measuring about 2*1.5 cm,firm ,mobile and
non tender.left sided node measuring 2*1 cm,
firm,mobile and non tender,FNAC done in right
inguinal node showing metastatic squamous
cell carcinomatous deposits.
.Following which CT picture taken which
showed supraglottic growth/hypopharyngeal
growth with level II necrotic cervical nodes.
FIGURE 3: Showing the metastatic
carcinomatous deposits in the right inguinal
node.
LOW POWER VIEW :
Patient 2: Venkatesh 60/M came with the c/o
bleeding rectum for 3 months.o/e right
inguinal node measuring 1*.5 cm, firm, mobile
and non-tender. Left inguinal region –free.
FNAC done in the right inguinal node showed
the picture in figure 2.
FIGURE 2: Metastatic carcinomatous deposits
showing focal areas of melanin pigments in
the node –s/o malignant melanoma.
HIGH POWER VIEW:
LOW POWER VIEW:
HIGH POWER VIEW:
Later thorough clinical examination done and
PATIENT found to have an ulcerated growth in
the penis measuring about 4*2 cm
Discussion:
Following this colonoscopy done in which we
found black nodular growth seen extending
from the anal verge - melanoma anal canal
Enlarged lymph nodes are accessible
for FNAC and are of importance specially to
diagnose secondary or primary malignancies. It
plays a significant role in developing countries
like India, as it is a cheap procedure, simple to
perform and has almost no complications. The
diagnosis given on the cytological material is
often the only diagnosis accepted and
sometimes there is no further correlation with
20
histopathology, especially in cases of
inoperable advanced malignancies. It also
provides clues for occult primaries and
sometimes also surprises the clinician who
does not suspect a malignancy.
Enlarged lymph nodes are easily accessible for
fine needle aspiration and hence fine needle
aspiration cytology (FNAC) is a very simple, less
time consuming, cost effective and important
diagnostic tool for lymph node lesions.
Among the adult patients with isolated
palpable lateral neck swelling, approximately
20% were diagnosed as malignancy in the
lymph node, mostly metastasis from primary
squamous cell carcinoma in the head and neck.
In most cases, they presented as a firm and
solid mass in the corresponding chain of the
lymph node, the cytological diagnosis of which
did not pose any problem. An important clue
to the diagnosis of metastatic (supraglottic
growth) SCC is the presence of necrosis and
keratinization, which is better appreciated on
Pap stain than on H & E stain. SCC can be easily
confused with a cystic lesion or pilomatrixoma,
especially when head and neck region is
involved. This showed only necrosis and/or
cystic change on FNAC but revealed SCC on
histology. The cytologic appearance of
squamous cell carcinoma depends upon the
degree of differentiation by the tumor.
Keratinizing cancers are readily identified
when cells with abundant sharply demarcated
dense eosinophilic cytoplasm and pyknotic
nuclei are present in smears. Non keratinizing
squamous cell carcinoma are represented by
round, oval or polygonal cells with sharply
demarcated pale cytoplasm and coarsely
granular nuclear chromatin.
Penile cancer social usually originates in the
epithelium of the glans penis. There is a
tendency for the early signs to be ignored so
that they often present late. 95%of the penile
cancers are squamous cell carcinoma social
AND psychological impact of the disease in the
person is highly significant. The cause of penile
squamous cell carcinoma is unclear but Human
papilloma virus (HPV)appears to be an
important causative factor. Lymphatic spread
from the carcinoma penis is first to the deep
and superficial inguinal nodes and then the
pelvic nodes. Enlarged lymph nodes may also
be due to secondary infection and a foul,
purulent discharge may be noted. Other sites
of Distant metastasis being liver and lung.
Malignant anorectal melanoma arises from the
melanocytic cells in the anal mucosa. The
tumor often invades the lamina propria, filling
it with proliferating melanoma cells .Later
proliferation of malignant cells often forms a
bulky tumor that can project into the anal canal
following which the patient presents clinically.
Because of the rich vascular and lymphatic
supply, lymph node enlargement being the
earliest. Rectal tumors often metastasize to
pelvic nodes, and anal canal tumors to inguinal
lymph nodes.
Conclusion:
FNAC of lymph nodes is a very useful,
cost effective, time effective, simple tool in the
diagnosis of lymph node metastasis. It may be
the only tool in the diagnosis of metastatic
lesions in the lymph nodes and can help to
detect occult primary malignancies. Hence, the
cytopathologist plays a vital role in the
diagnosis of lymph node metastasis. FNAC is a
rapid, safe, easy and non-expensive diagnostic
technique which can be used for initial
diagnosis of metastatic lymphadenopathy, in a
resource challenged environment, confirm
secondaries where primary tumor is evident,
and for response to treatment.
REFERENCES:
21
1. Bagwan IN, Kane SV, Chinoy RF. Cytologic
evaluaton of the enlarged neck node: FNAC
utility in metastatic neck disease. Int J Pathol
2007;6:2
2. Alam K, Khan A, Siddiqui F, Jain A, Haider N,
Maheshwari V. Fine needle aspiration cytology
(FNAC): A handy tool for metastatic
lymphadenopathy. Int J Pathol 2010;10:2
3. Khajuria R, Goswami KC, Singh K, Dubey VK.
Pattern of lymphadenopathy on fine needle
aspiration cytology in Jammu. JK Sci
2006;8:157-9
4. Hirachand S, Lakhey M, Akhter P, Thapa B.
Evaluation of fine needle aspiration cytology of
lymph nodes in Kathmandu Medical College,
Teaching hospital. Kathmandu Univ Med J
2009;7:139-42
5. Ahmad T, Naeem M, Ahmad S, Samad A,
Nasir A. Fine needle aspiration cytology (FNAC)
and neck swellings in the surgical outpatient.
JAMC 2008;20:30-2]
22
PRIMARY MATURE RETROPERITONEAL TERATOMA
INVOLVING THE ADRENAL GLAND.
K.Chandramouleeswari 1, Sujay Surikar2
ABSTRACT
Retroperitoneal mature cystic teratoma arising from the adrenal gland is a rare retroperitoneal
tumor accounting for only 4% of all primary teratomas. Though mature cystic teratomas of extra
gonadal sites are unusual, (1) those arising in the adrenals are exceptionally rare. (2, 3) They are
more common in childhood and rarely occur in adults. (4) Only very few cases, mostly in young
patients have been reported. Most teratomas in this region are secondary to germ cell tumors of
the testicles or ovaries. To be very specific, in male patients, retroperitoneal germ cell tumors are
more likely to have metastasized from the testes than presenting as primary tumors. On histological
examination, they are composed of variable proportions of tissue originating from the ectoderm,
mesoderm, and endoderm. Although gastrointestinal epithelium is occasionally seen in these
tumors, the presence of a complete intestinal wall is rare. We report a case of primary mature
cystic teratoma involving the left adrenal gland with portion of the mature component being
intestinal wall.
KEYWORDS:
Adrenal gland, colonic wall, mature cystic teratoma
Introduction:
23
Primary mature cystic teratomas are
uncommon non-seminomatous germ cell
tumors. They are made up of welldifferentiated parenchymal tissues that are
derived from more than one of the three germ
cell layers (6). They usually occur in midline
structures. The most common sites are gonads
followed by extra gonadal sites such as
intracranial,
cervical,
mediastinal,
retroperitoneal, and sacrococcygeal regions
(7). Primary retroperitoneal teratomas
involving adrenal glands are exceedingly
uncommon accounting for only 4% of all
primary teratomas (7-9). Only a very few case
reports have been documented in literature so
far (10). The majority of cases are
asymptomatic, present with nonspecific
complaints, or identified incidentally on
routine investigations (11). Confirmatory
diagnosis of mature teratoma comes by
histopathological examination (12). Prognosis
is fortunately excellent after complete surgical
excision remains the mainstay of treatment
and prognosis is excellent after resection (13).
Herein, we report a mature cystic
retroperitoneal teratoma in the region of left
1. Govt. Stanley Medical College & Hospital, Chennai
2. Govt. Royapettah Hospital, Chennai
adrenal gland in an otherwise healthy female
patient who presented with a 1-month history
of left flank pain and hypertension.
Case report:
A 45 year old female presented with
flank pain for one month and incidental
hypertension. On physical examination, a
mobile mass in the flank was identified. All
other laboratory investigations were normal.
CT abdomen was done and the patient was
found to have a mass in the left retroperitoneal
region involving the adrenals. A diagnosis of
phaeochromocytoma was made because of
the coexisting hypertension and surgical
resection was advised. Resection of the mass
in toto was performed and sent for
histopathology.
Grossly, the resected mass measured 12x10x8
cms. Surface was smooth and lobulated. Cut
section shows a multiloculated cyst filled with
grey white material and adipose tissue with
focal areas of calcification. Multiple sections
were taken and submitted for histopathology.
Sections revealed fibro muscular wall lined
partly by respiratory and partly by intestinal
epithelium. Focal area showed a portion
Fig.1 – Gross picture of
retroperitoneal cystic teratoma
mature
Fig .2 – 10x view showing adipose tissue and
mature cartilage.
histologically resembling wall of the large
intestine. Lobules of mature adipose tissue,
Spicules of mature bone and cartilage
identified. A diagnosis of retroperitoneal
teratoma involving the left adrenal gland was
made. No immature elements were identified.
With respect to laboratory investigations,
retroperitoneal teratomas can express a
diversity of serum tumor markers such as
elevated
alpha-fetoprotein
(AFP),
carcinoembryonic antigen (CEA), and CA 19-9.
These serum tumor markers are helpful in
clinical practice and can be used to monitor
successful treatment or detect relapse in
patients with specific tumor marker-secreting
teratomas. The diagnosis of adrenal teratoma
relies predominantly on an imaging
examination because the findings from
laboratory examinations will often be normal.
On CT scans, teratoma is frequently shown as
a heterogeneous fat dense mass with
calcifications. Mature teratoma in the adrenal
region can mimic other types of lipomatous
adrenal tumor. The differential diagnosis of
retroperitoneal teratomas include ovarian
tumors, renal cysts, adrenal tumors,
retroperitoneal fibromas, Wilms’ tumor,
sarcomas, hemangiomas, neonatal cystic
neuroblastoma, xantogranuloma, congenital
mesoblastic nephroma, enlarged lymph nodes
and
perirenal
abscess
Discussion:
Generally, teratomas arise from uncontrolled
proliferation of pluripotent cells: germ cells
and embryonal cells. The type of pluripotent
cell giving rise to the tumor greatly influences
the presentation time and site of teratoma.
Teratomas of germ cell sources can be
congenital or acquired and are usually found in
gonads (6,7) . In contrast, teratomas of
embryonic cell sources are always congenital
and are usually found in extra gonadal
locations, such as intracranial, cervical,
retroperitoneal,
mediastinal,
and
sacrococcygeal sites (11-15).
Teratomas can be diagnosed based on high
index of clinical suspicion, routine laboratory,
and radiographic investigations (17,18). With
respect to high index of clinical suspicion,
retroperitoneal teratomas involving adrenal
glands may present congenitally, or later in life
when they grow to massive sizes (19). Clinical
presentations are variable and include
nonspecific
back
pain,
obstructive
gastrointestinal and genitourinary symptoms,
as well as lower limb swelling due to lymphatic
obstruction. They can rarely present with
complications such as secondary infections,
traumatic rupture leading to acute peritonitis,
or malignant transformations.
Fig.3 – 10x view showing intestinal wall.
24
Conventional imaging techniques cannot
exactly distinguish the various types of
lipomatous tumor. Histopathology gives the
final confirmatory diagnosis.
Conclusion:
Adrenal teratomas have been reported
extremely rarely in adults, it should be
considered in the differential diagnosis of
hormonally silent adrenal tumors. In
particular, teratoma should be considered in
the differential diagnosis of adrenal
lipomatous tumors, not only in children and
young adults, but also in elderly patients. The
final diagnosis depends on the findings of the
pathological examination. Once complete
resection of the tumor has been made and
the diagnosis is accomplished, prognosis for
such patients is excellent with 5 year survival
being 100%.
CONFLICT OF INTEREST:
Dr. Chandramouleeswari, although a member of Editorial Board, did not participate in the review of
this case report which was done by an independent and autonomous panel.
REFERENCES:
1.Selimoglu E, Oztürk A, Demirci M, Erdogan F.
A giant teratoma of the tongue. Int J Pediatr
Otorhinolaryngol 2002;66:189-92.
2.Li Y, Wu H, Yao G, Zhao X. Diagnosis and
treatment of mature adrenal teratoma. Zhong
Nan Da Xue Xue Bao Yi Xue Ban 2011;36:174-7.
3.Sato F, Mimata H, Mori K. Primary
retroperitoneal mature cystic teratoma
presenting as an adrenal tumor in an adult. Int
J Urol 2010;17:817.
4.Goyal M, Sharma R, Sawhney P, Sharma MC,
Berry M. The unusual imaging appearance of
primary retroperitoneal teratoma: Report of a
case. Surg Today 1997;27:282-4.
5.Fujiwara K, Ginzan S, Silverberg SG. Mature
cystic teratomas of the ovary with intestinal
wall structures harboring intestinal-type
epithelial
neoplasms.
Gynecol
Oncol
1995;56:97-101.
6. D. J. B. Ashley, “Origin of teratomas,”
Cancer, vol. 32, no. 2, pp. 390–394, 1973.
25
7. S. Bedri, K. Erfanian, S. Schwaitzberg, and A.
S. Tischler, “Mature cystic teratoma involving
adrenal gland,” Endocrine Pathology, vol. 13,
no. 1, pp. 59–64, 2002.
8. J. L. Polo, P. J. Villarejo, M. Molina et al.,
“Giant mature cystic teratoma of the adrenal
region,”American Journal of Roentgenology,
vol. 183, no. 3, pp. 837–838, 2004.
9. J. L. Grosfeld and D. F. Billmire, “Teratomas
in infancy and childhood,” Current Problems in
Cancer, vol. 9, no. 9, pp. 1–53, 1985.
10. M. Goyal, R. Sharma, P. Sawhney, M. C.
Sharma, and M. Berry, “The unusual imaging
appearance of primary retroperitoneal
teratoma: report of a case,” Surgery Today, vol.
27, no. 3, pp. 282–284, 1997.
.11. J. P. K. Hui, W. H. Luk, C. W. Siu, and J. C. S.
Chan, “Teratoma in the region of an adrenal
gland in a 77-year-old man,” Journal of the
Hong Kong College of Radiologists, vol. 7, no. 4,
pp. 206–209, 2004.
12. P. Mathur, M. A. Lopez-Viego, and M.
Howell, “Giant primary retroperitoneal
teratoma in an adult: a case report,” Case
Reports in Medicine, vol. 2010, Article ID
650424, 3 pages, 2010.
13. H. Liu, W. Li, W. Yang, and Y. Qi, “Giant
retroperitoneal teratoma in an adult,”
American Journal of Surgery, vol. 193, no. 6,
pp. 736–737, 2007.
14. C. W. Pinson, S. G. ReMine, W. S. Fletcher,
and J. W. Braasch, “Long-term results with
primary retroperitoneal tumors,” Archives of
Surgery, vol. 124, no. 10, pp. 1168–1173, 1989.
17.
C. J. Logothetis, M. L. Samuels, A.
Trindade, and D. E. Johnson, “The growing
teratoma syndrome,”Cancer, vol. 50, no. 8, pp.
1629–1635, 1982.
15.
J. Collen, M. Carmichael, and T.
Wroblewski, “Metastatic malignant teratoma
arising from mediastinal nonseminomatous
germ cell tumor: a case report,” Military
Medicine, vol. 173, no. 4, pp. 406–409, 2008.
16.
D. Harms, S. Zahn, U. Göbel, and D. T.
Schneider, “Pathology and molecular biology
of teratomas in childhood and adolescence,”
Klinische Padiatrie, vol. 218, no. 6, pp. 296–
302, 2006.
18.
V. Gupta, H. Garg, A. Lal, K. Vaiphei,
and S. Benerjee, “Retroperitoneum: a rare
location of extragonadal germ cell tumor,” The
Internet Journal of Surgery, vol. 17, no. 2,
article 9, 2008.
19.
H. G. Gatcombe, V. Assikis, D. Kooby,
and P. A. S. Johnstone, “Primary
retroperitoneal teratomas: a review of the
literature,” Journal of Surgical Oncology, vol.
86, no. 2, pp. 107–113, 2004.
26
DESMOPLASTIC SUPRATENTORIAL NEUROEPITHELIAL TUMOR
OF INFANCY WITH DIVERGENT DIFFERENTIATION- A RARE
CASE REPORT
P.Arunalatha1, A.Srimahalakshmi1, K. Chandramouleeswari1, Karthika1
ABSTRACT
Desmoplastic infantile gangliogliomas are rare, superficial, supratentorial tumor presenting in
early childhood, they occur within first two years of life and represent 1.25% of all intracranial
tumors in children. A 3 year old female child with right fronto parietal desmoplastic infantile
ganglioglioma who was successfully managed with surgery is presented here.
Key words:
Frontoparietal, Desmoplastic, Supratentorial.
Introduction:
Desmoplastic infantile ganglioglioma
(DIG) was first described by Vanden Berg et al
in 1987. Despite their regular content of poorly
differentiated and proliferative small cell
elements, desmoplastic infantile astrocytomas
and gangliogliomas are currently accorded
WHO Grade I status. They are benign CNS
tumors that develop virtually exclusively in
infants younger than 2 years, often as a
remarkably large solid and cystic hemispheric
mass that may replace much of the brain on
one side. Presents commonly with increasing
head circumference and bulging fontanalle.
Lymph nodes are common site of metastases
for different cancers. Thus clinical recognition
and
urgent
diagnosis
of
palpable
lymphadenopathy is of paramount importance
specially
to
differentiate
between
inflammatory lesions or metastatic or primary
neoplastic tumor.
abundant desmoplasia with a neoplasm
composed of spindle cells (Fig 3) arranged in a
storiform pattern with areas of adipocytic
differentiation (Fig 4). PNET (Primitive neuro
ectodermal tumor) like area is seen focally
reflecting neuronal differentiation. Small
inconspicuous gemistocyte like cells along with
few ganglion cells seen (Fig 5). GFAP was done
and is positive (Fig 6).
Case report:
27
A 3 years old female child presented
with hemiparesis and right fronto-parietal
space occupying lesion. CT scan revealed solid
area and two communicating cystic lesions,
one clear and the other with thick internal
septations with surrounding edema and
midline shift (Fig 1). Gross also showed a well
circumscribed solid and cystic mass measuring
6x5x3 cms (Fig 2). Histopathology showed
1. Govt. Stanley Medical College & Hospital, Chennai
Fig 1: CT scan showing cystic and solid mass
with internal septation and surrounding
oedema
Fig 5: PNET like area seen focally
Fig 2: Well circumscribed solid and cystic mass
measuring 6x5x3 cms
Fig 3: Cellular neoplasm showing spindle cells
with areas of desmoplasia
Fig
4:
Tumor
differentiation
showing
adipocytic
Discussion:
Vanden Berg et al in 1987 first coined
the terms as Desmoplastic infantile
ganglioglioma and desmoplastic infantile
astrocytoma
on
the
basis
of
immunohistochemistry
and
electron
microscopy. They have identical clinical and
radiological features and have favourable
outcome following excision, so they are
included as distinctive group in revised WHO
classification of brain tumors (1). A
frontoparietal localization is most common,
many of these sizable lesions spanning more
than one cerebral lobe. Desmoplastic infantile
astrocytomas
and gangliogliomas are
characteristically associated with evidences of
rapidly evolving supratentorial mass effect as
manifested in the very young. Increasing head
circumference, bulging fontanelles, and forced
downwards deviation of the eyes (the ‘sunset
sign’) are commonly observed. CT or MRI show
a superficially positioned, multinodular, and
brightly contrast-enhancing supratentorial
mass attached to dura in plaque-like fashion
and associated with a subjacent, uni- or multiloculated cyst with intracranial shifts and other
mass effects. Calcification has not been
reported in these tumors (2).
The solid components of the desmoplastic
cerebral astrocytoma and ganglioglioma are
composed of tan to a gray-white tissue that is
rubbery in consequence of its collagenisation.
Histologically, it resembles a mesenchymal
neoplasm such as a fibroma or malignant
fibrous histiocytoma because of the dense
collagen deposition and prominent spindled
elements arranged in fascicular and storiform
patterns. Meningeal and dural involvement is
also common, thus further contributing to the
perception of a mesenchymal derivation. The
glial elements are often inconspicuous and
28
proliferative activity raises the differential
diagnosis of PNET, although the more
differentiated histologic elements and
characteristic desmoplasia are also present.
Malignant gliomas similarly lack this
desmoplasia, a neuronal component, and the
characteristic clinic-radiologic features.
Fig 6: GFAP positivity
range from small gemistocyte-like to spindled
cells. Neuronal components are also present in
DIG and typically take the form of small
ganglion-like cells. These cells are similarly
enmeshed in a spindled, reticulin-rich
desmoplastic
background.
Primitive
neuroectodermal tumor (PNET)-like foci are
common and consist of hypercellular foci with
small round cells, increased mitotic activity, or
necrosis. Immunostains highlights both GFAPpositive astrocytes and synaptophysin-positive
neurons. The MIB-1 labeling index is typically
low, except in PNET-like foci, where it may be
markedly elevated.
The differential diagnosis includes reticulin rich
desmoplastic tumors such as Pleomorphic
xanthoastrocytoma (differentiated by age,
lipidization and absence of neural component)
and Gliofibroma (usually infratentorial and
lacks neural component)(2). Because of the
desmoplasia, spindled morphology, and
frequent dural attachment, the differential
diagnosis includes benign and malignant
mesenchymal tumors, as well as fibrous
meningioma.
Careful
inspection
and
Immunohistochemistry reveal the glial, and in
the case of DIG, the neuronal elements. The
presence of small blue cells with increased
The differential diagnosis for large cells with
eccentrically located nuclei and abundant
unipolar cytoplasm in an aspiration specimen
of a cerebral mass in a young person includes
DIG, atypical teratoid/rhabdoid tumor (AT/RT),
dysembroplastic neuroepithelial tumor (DNT),
ganglioglioma, supratentorial PNET with
ganglionic
differentiation
(ganglioneuroblastoma), anaplastic large cell
lymphoma
and
pleomorphic
xanthoastrocytoma(3). Clinical features as well
as immunohistochemical analysis will help to
differentiate these conditions. AT/RT will have
loss of Integrase interactor-1, which can be
detected immunohistochemically (INI-1) and
the rhabdoid cells in this condition express
vimentin. The role of adjuvant therapy is yet
very limited. Chemotherapy is given only to
those patients having high-grade tumors
showing brisk mitosis, aneuploidy and
increased MIB labeling. It is also given to
patients with tumors involving eloquent
regions of the brain not amenable for surgery
(4).
Conclusion:
In spite of alarming clinical features
with large size and PNET like foci, it is
considered a WHO grade 1 neoplasm and has
excellent prognosis. Spontaneous regression
has been shown to occur in some cases
following subtotal resection.
CONFLICT OF INTEREST:
Dr. Chandramouleeswari, although a member of Editorial Board, did not participate in the review of
this case report which was done by an independent and autonomous panel.
29
REFERENCES:
1.
D. Balasubramanian, V. G. Ramesh, K.
Deiveegan, Mitra Ghosh, V. S. Mallikarjuna, T.
P. Annapoorneswari, N. Chidambaranathan, K.
V. N. Ramani. Desmoplastic infantile
ganglioglioma - A case report. Neurology India
September 2004 Vol 52 Issue 3
2.
Bita
Geramizadeh,
Ahmad
Kamgarpour, and Ali Moradi. Desmoplastic
infantile ganglioglioma: Report of a case and
review of the literature. J Pediatr Neurosci.
2010 Jan-Jun; 5(1): 42–44. doi: 10.4103/18171745.66669
3.
Oluwole Fadare, M Rajan Mariappan,
Denise Hileeto, Arthur W Zieske, Jung H Kim,
Idris Tolgay Ocal. Desmoplastic Infantile
Ganglioglioma: cytologic findings and
differential diagnosis on aspiration material.
CytoJournal 2005, 2:1
4.
Khubchandani SR, Chitale AR, Doshi
PK. Desmoplastic non-infantile ganglioglioma:
A low grade tumor, report of two patients.
Neurol India 2009;57:796-9
30
SECONDARY OMENTAL INFARCTION DUE TO
DUODENAL PERFORATION
Pandiaraja Jayabal, Viswanathan Subramanian
ABSTRACT
Omental infarction is a rare cause of acute abdomen in adult [1]. Omental infarction is classified as
primary when there is no coexisting causative condition identified or secondary when there is
association with causative condition. Omental infarction more common in male compared to
female and frequently occurs in fourth or fifth decade of life.
Case report:
This is a case report of 45years old male who is chronic alcoholic presented with features
of hollow viscus perforation. Intra operative findings show secondary Omental infarction due to
duodenal perforation.
In most of Omental infarction cases was misdiagnosed. But proper radiological investigations with
diagnostic laproscopy improve diagnostic accuracy. High index of suspicion is needed for diagnosis
of Omental infarction. Secondary Omental infarction has poor prognosis compared to primary
Omental infarction due to underlying disease pathology. Management of omental infarction by
either conservative or surgical management by patient presentation or radiological findings.
Secondary Omental infarction due to hollow viscus perforation is a dangerous combination,
because loss of omentum allow localized pathology to become generalized peritonitis with higher
morbidity with mortality. So early recognition and prompt treatment reduces complications.
Key words:
Omental infarction, duodenal perforation, right and left gastroepiploic arteries.
Case:
A 45 yrs old male patient who is
known alcoholic and smoker for 20 years
duration admitted with complaint of
abdominal pain for 4 days duration associated
with history of nausea and vomiting for 3 days
duration. On examination patient was
conscious, oriented, and febrile. Pulse rate 110/min, BP- 80/60mmhg. Abdominal
examination shows distended abdomen. On
palpations guarding and rigidity was present.
Tenderness more on epigastric and right
hypochondrial region. Free fluid present. On
auscultations bowel sound was absent [fig .1]
31
Investigations show anemia with
leucocytosis. Elevated renal function test and
liver function parameters. Renal function test
shows severe dyslectrolytemia (hypokalemia).
Erect abdominal x rays shows free gas under
diaphragm [fig. 2]. CT abdomen shows free
fluid [fig .3]. Abdominal paracentesis shows
black fluid aspirate. Pre-operative diagnosis
made as hollow viscus perforation and
laparotomy done. Intra operative findings
show a single 1x1cm perforation in the 1st part
of duodenum with Omental infarction [fig. 4, 5,
6]. Gangrenous toxic fluid around 3litre was
aspiration. As the patient in the morbid
condition primary closure of duodenal
perforation with omentectomy done along
with peritoneal cavity was irrigated with
normal saline. Post operative period patient on
inotropic support. During 3rd post operative
day patient died inspite of resuscitation.
Discussion:
The omentum is rich in lymphatics and
blood vessels. The omentum becomes densely
adherent to intraperitoneal sites of
inflammation for prevention of localized
pathology to diffuse peritonitis. Omental
infarction is a rare cause of acute abdomen
with an incidence equivalent to less than four
cases per 1000 cases of appendicitis [2]. Low
incidence and non-specific presentation
contribute to Omental infarction being
misdiagnosed for appendicitis, peptic ulcer
Figure 3 - CT abdomen show air fluid level
Classification and aetiology:
Figure 1- Abdomen show distension with
guarding and rigidity
disease, cholecystitis, pancreatitis among
other abdominal pathology [2]. Omental
infarction is classified as primary or secondary
based on etiology. Diagnosis of primary
Omental infarction is made when there is no
cause, whereas diagnosis of secondary made
when there is association with pathology.
Primary
Secondary
Obesity
Cyst and tumor
Local trauma
Internal hernia
Heavy food intake
Diverticulitis
Chronic cough
Vasculitis and hyper
coagulation status
Sudden body
movements
Polycythemia
Laxative use
Omental torsion
Hyper peristalsis
adhesions
Occupational
vibrations
Laparoscopic assisted
distal gastrectomy
Excessive exercise
Right heart failure
Figure 4 - Intra operative picture show duodenal
perforation
Figure 2- Xray erect abdomen- show air under
diaphragm
32
(Fig. 5) Omental infarction with perforation
Pathogenesis:
1. Right half of the omentum more commonly
involved due to anatomically altered
vasculature, less tolerant of spontaneous
venous stasis and thrombosis secondary to
stretching of Omental veins.
2. Fatty accumulation in the omentum
impedes the distal right epiploic artery and
additional structural mass potentially
precipitates torsion [1].
3. A longer mobile right side greater omentum
potentially prone for torsion induced Omental
infarction [7].
4. Obesity causes irregularly distributed
accumulations of excess omentum and
increased fat deposits reduces blood supply to
the thickened omentum.
Epidemiology:
Correct pre-operative diagnosis of primary
Omental infarction was possible only in 0.6 to
4.8% of all cases. Primary cause of Omental
infarction is generally unidentified and the
condition may develop with or without torsion.
It was first reported by Bush in 1896.
Radiological features
33
CT finding of an ill-defined heterogeneous
mass or interspersed fatty lesion with hyper
attenuating streaky infiltration located in the
omentum in early stage, and thus progress to a
well-defined, smaller lesion with hyper dense
(Fig. 6) Omental infarction
rim in the late phase [8]. Concentric linear
strands or the whirl sign and hyper attenuating
streaky infiltration both are path gnomonic
feature of Omental torsion.
Management:
Park et al argue that on collective balance,
surgery should not be first line of
management, particularly as better imaging
accessibility forgoes the need for surgery [7].
But some authors recommending for surgical
management by means of laparoscopic
approach
is better
for considering
complication.
Conclusion:
In most of Omental infarction cases was
misdiagnosed. But proper radiological
investigations with diagnostic laparoscopy
improve diagnostic accuracy. High index of
suspicion is needed for diagnosis of Omental
infarction. Secondary Omental infarction has
poor prognosis compared to primary Omental
infarction due to underlying disease pathology.
Management of Omental infarction by either
conservative or surgical management by
patient presentation or radiological findings.
Secondary Omental infarction due to hollow
viscus perforation is a dangerous combination,
because loss of omentum allow localized
pathology to become generalized peritonitis
with higher morbidity with mortality. So early
recognition and prompt treatment reduces
complications.
REFERENCES:
1.
Puylaert JB. Right-sided segmental
infarction of the omentum: clinical, US, and CT
findings. Radiology 1992;185:169-172
2.
Itenberg E, Mariadason J, Khersonsky
J, Wallack M. Modern management of omental
torsion and omental infarction: a surgeon’s
perspective. J Surg Educ 2010;67(January–
February (1)):44–7.
3.
Theriot JA, Sayat J, Franco S, Buchino
JJ. Childhood obesity: a risk factor for omental
torsion. Pediatrics 2003;112:e460
4.
Wiesner W, Kaplan V, Bongartz G.
Omental infarction associated with right-sided
heart failure. Eur Radiol 2000;10:1130-1132
5.
Kim MC, Jung GJ, Oh JY. Omental
infarction following laparoscopy-assisted
gastrectomy (LAC) for gastric cancer. J Korean
Gastric Cancer Assoc 2010;10:13-18.
6.
Fragoso AC, Pereira JM, Estevão-Costa
J. Nonoperative management of omental
infarction: a case report in a child. J Pediatr
Surg 2006;41(October (10)):1777–9.
7.
Park TU, Oh JH, Chang IT, Lee SJ, Kim
SE, Kim CW, et al. Omental infarction: case
series and review of the literature. J Emerg
Med 2008
8.
Singh AK, Gervais DA, Lee P, Westra S,
Hahn PF, Novelline RA, et al. Omental infarct:
CT imaging features. Abdom Imaging
2006;31:549-554
34
FACTITIOUS DISORDER
V.Venkatesh Mathankumar1, S.Manikandan1, C.Senthil Kumaran1, Mohamed Ilyas1,
R.Saravana Jothi1, T.V.Asokan1
Introduction:
Factitious disorder is characterized by
knowingly repeated simulation of physical
symptoms for the sole purpose of obtaining
medical care and attention. Unlike malingering
there is no obvious recognizable gain in
assuming the sick role. The presenting
symptoms may mimic various medical illnesses
like fever, seizures, bronchial asthma,
haematuria, oliguria, renal colic, diplopia, and
blepharospasm. The exaggeration of a preexisting condition has also been reported and
it is also included under factitious disorder.
Here we report an interesting case where the
patient complained of finding live insects
crawling out of her ears.
Case Report:
35
A 9 years old girl hailing from a village
near Villupuram, Tamilnadu was brought by
her family members to the ENT OPD. The
complaints started when the patient found an
insect crawling out of her left ear 3 months
back. She complained of headache before
finding the insect. Thereafter the girl would
detect insects frequently, once or twice a week
from both ears and show these insects to her
grandmother. None of the family members
themselves saw the insect crawling out of the
patient’s ear. There was a past history of
chronic suppurative otitis media (CSOM) right
ear a few years back and there was some
occasional discharge from right ear. There was
no past history of any psychiatric illness. Family
history was not contributory. In view of no
objective evidence of any ear pathology
following several investigations, the case was
referred to psychiatry OPD. The patient was
admitted and detailed psychiatric evaluation
was made. There were no instances of insect
detection during the hospital stay and on
1. Govt. Stanley Medical College & Hospital, Chennai
gentle probing the girl revealed that she never
found any insect crawling from her ear. She
harboured no delusions about being infested
with insects or being seriously ill. She reported
no difficulty in hearing. Detailed probing did
not reveal any economic or material gain on
account of the illness. Interestingly the child
had witnessed a magico-religious ritual
involving extraction of insects from ear a few
months back.
Discussion:
Factitious disorder according to DSM 5
(Diagnostic and Statistical Manual of Mental
Disorders) is diagnosed when there is a
falsification of physical or psychological
symptoms with deception in the absence of
any external rewards. Such behaviour is not
better explained by any other mental disorder.
It differs from malingering as there is no
monetary or legal gain in producing the
symptoms. The sole purpose is just to assume
a sick role and get medical attention. Another
variant is the factitious disorder by proxy
where the falsification of symptom is done by
another person most commonly by the caregiver. In such cases the perpetrator receives
the diagnosis.
Conclusion:
Factitious disorders can cause
significant morbidity and health care expense
due to various investigations. This case
highlights the need to consider factitious
disorder as a differential diagnosis whenever a
bizarre clinical presentation is encountered
with no plausible explanation so that
unnecessary
expensive
and
invasive
investigations can be avoided. However it is to
be noted that a diagnosis of factitious disorder
does not rule out any true medical or
psychiatric illness as co-morbid illnesses can
always occur and specific therapeutic
interventions are required for the same.
REFERENCES:
1. Asher, R. (1951) Munchausen's syndrome.
Lancet, 1, 339-341.
2. Black, D. (1981) The Extended Munchausen's
syndrome: A family case. British Journal of
Psychiatry, 138, 466-469
3. Bhugra, D. (1988). Psychiatric Munchausen's
Syndrome. Acta Psychiattrica Scandinavica, 77,
497-503.
5. Feldman MD. Untangling the Web of
Munchausen Syndrome, Munchausen by
Proxy, Malingering, and Factitious Disorder.
New York: Brunner-Routledge; 2004. Playing
Sick? pp. 18–32.
6. Shilling C. Culture, the ‘sick role’ and the
consumption of health. Br J Sociol.
2002;53(4):621–638
7. Krahn LE, Li H, O’Connor MK. Patients who
strive to be ill: factitious disorder with physical
symptoms. Am J Psychiatry. 2003;160(6):11631168.
4. American Psychiatric Association: Diagnostic
and Statistical Manual of Mental Disorders (
DSM 5 )
36
PSYCHIATRIC MANIFESTATIONS AND
NEURO-COGNITIVE PROBLEMS ASSOCIATED WITH HIV
V.Venkatesh Mathankumar1, C.Senthil Kumaran1, Mohamed Ilyas1, R.Saravana Jothi1 ,
T.V.Asokan1
ABSTRACT
HIV associated neuro-cognitive disorder is a blanket term that covers a spectrum of neuro-cognitive
disturbances in HIV infected individuals ranging from asymptomatic neuro-cognitive
impairment(ANI) to HIV associated dementia(HAD). With the institution of combination of retroviral
drugs for the treatment, the incidences of severest forms have decreased over the years and the
milder forms are more often encountered in clinical setting.
Key words:
HIV associated neuro-cogntive disorder, AIDS dementia complex; HIV-associated dementia
(HAD); HIV encephalopathy
Case:
43 years old male, with positive HIV
status for the past 12 years on HAART was
referred to Psychiatry OPD for complaints of
irrelevant excessive talk, using different names
for others, sleep disturbance for past two
months. The patient has been on regular
follow up and continuous treatment for the
past 12 years. There was no family history
suggestive of any psychiatric illness. On
examination, there was no focal neurological
deficits or signs suggestive of acute CNS
infection. Initial verbal responses were in
tandem with the conversation and later on it
was found to be tangential with increased
fluency. Psychomotor activity as well as
quantum, tone and speed of talk were
increased. Mood was apathetic. There were no
delusions or hallucinations. Lobar function test
revealed perseveration. All the basic
investigations were normal. Viral markers for
HBV and HCV infections were negative and CSF
analysis was normal. CD4 count was 124.
Neroimaging (MRI) revealed prominent sulci
and gyri, dilated ventricles and periventricular
hyperintensity. Though neuroimaging findings
such as prominent sulci and gyri, dilated
ventricles and periventricular hyperintensity
point towards HIV related neurocognitive
37
1. Govt. Stanley Medical College & Hospital, Chennai
disorder, clinically in addition to psychiatric
manifestations
patient
presents
with
perseveration only. So this may be construed
as atypical HIV neurocognitive disorder which
should be confirmed with the follow up.
Discussion:
Major neuro-cognitive disorder due to
HIV is diagnosed when there is an evidence of
cognitive decline from a previous level of
functioning in one or more domains (Memory,
attention, language, learning, perceptualmotor etc). The decline in these domains must
cause significant interference in day to day
activities. The decline should not occur due to
delirium or due to any other mental disorder.
Another diagnostic entity described in
Diagnostic and Statistical Manual of Mental
disorders (DSM 5) is minor neuro-cognitive
disorder due to HIV which is diagnosed when
there evidence of cognitive decline but it does
not cause any interference in daily activities.
Conclusion:
Whenever a case of HIV infection is
diagnosed, it is important to evaluate the
neuro-cognitive profile as early as possible.
This is important because HIV infection has a
long window period and the neurocognitive
deterioration might have started even before
the diagnosis is made. There have been
instances of HIV infection presenting with
neurocognitive deficits alone. However it is
important to rule out other CNS infections and
HIV encephalopathy before making a diagnosis
of HIV associated neuro-cognitive disorder.
Low CD4 count and concurrent HCV infections
have been identified to accelerate the neurocognitive deterioration.In this regard the
psychiatric evaluation and neuro cognitive
assessment assumes greater significance to
initiate better supportive measures in the
therapeutic armamentarim
REFERENCES:
1. Powderly WG. Sorting through confusing
messages: the art of HAART. J Acquired Immune
Deficiency Syndrome 2002; 31(suppl 1):S24–5.
2. Antinori A, Arendt G, Becker JT, et al. Updated
research
nosology
for
HIV-associated
neurocognitive disorders. Neurology 2007;
69:1789–99.
3. Albert SM, Weber C, Todak G. An observed
performance test of medication management
ability in HIV: relation to neuropsychological status
and adherence outcomes. AIDS Behav 1999; 3:121–
8.
4. Berger JR, Brew B. An international screening tool
for HIV dementia.AIDS 2005; 19:2165–6.
5. Farinpour R, Miller EN, Satz P, et al. Psychosocial
risk factors of HIV morbidity and mortality: findings
from the Multicenter AIDS Cohort Study (MACS). J
Clin Exp Neuropsychol 2003; 25:654–70.
6.Dubé B, Benton T, Dean G, et al. Neuropsychiatric
manifestations of HIV infection and AIDS. J
Psychiatry Neurosci 2005; 30:237–46.
7.. Hawkins T, Geist C, Young B, et al. Comparison of
neuropsychiatric side effects in an observational
cohort of efavirenz- and protease inhibitor-treated
patients. HIV Clin Trials 2005;6:187–96.
8. Miller RF, Dave SS, Tang JW, et al. Progressive
neuropsychiatric problems following institution of
highly active antiretroviral therapy. Sex Transm
Infect 2005;81:351–7.
9. Moreno A, Labelle C, Samet JH. Recurrence of
post-traumatic stress disorder symptoms after
initiation of anti-retrovirals including efavirenz: A
report of two cases. HIV Med 2003;4:302–4.
10.. Tozzi V, Balestra P, Murri R, et al.
Neurocognitive impairment influences quality of
life in HIV-infected patients receiving HAART. Int J
STD AIDS 2004;15:254–9.
11. Paul R, Flanigan TP, Tashima K, et al. Apathy
correlates with cognitive function but not CD4
status in patients with human immunodeficiency
virus. J Neuropsychiatry Clin Neurosci 2005;17:114–
18.
38
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Mehta MN, Mehta NJ. Serum lipids and ABO
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Vol 2 | Issue 1 | January - March | 2015
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