Tropical Doctor

Evidence-based decision-making is less common in low- and middle-income countries where the research capacity remains low. Nepal, a lower-middle-income country in Asia, is not an exception. We conducted a rapid review to identify the trend of health research in Nepal and found more than seven-fold increase in the number of published health-related articles between 2000 and 2018. The proportion of articles with Nepalese researchers as the first authors has also risen over the years, though they are still only in two-thirds of the articles in 2018.

Our descriptive study examines the clinical profile of referred neonates who underwent exchange blood transfusion (EBT) and identifies possible interventions at peripheral hospitals to decrease their severe hyperbilirubinemia. Among the 38 neonates enrolled, the following were identified as potential clinical gaps in management: early discharge within 24 h of birth (57%); non-availability of ABORh blood grouping (43%); lack of anti-D immunoprophylaxis (75%); pathological weight loss because of inadequate breastfeeding (42%); and low usage of phototherapy. Because of late recognition, the mean age at admission was 5.4 ± 3.3 days, levels of total serum bilirubin (TSB) were 516.4 ± 123.1 µmol/L, and acute bilirubin encephalopathy (ABE) was seen in 45% of neonates. Rh iso-immunisation (39.5%), ABO iso-immunisation (21%) and sepsis (8%) were major risk factors for severe hyperbilirubinaemia. Quality prenatal screening identifying at-risk newborns, preventing early discharge after birth, a bilirubin nomogram risk assignment before discharge and assuring early recognition of hyperbiliubinaemia by parents may well minimise the incidence of EBT.

We reviewed the post-operative morbidity and mortality of open splenectomy undertaken in conjunction with selective blood transfusion in Jamaican children with sickle cell disease. Data were collected on 150 splenectomies performed between November 1994 and October 2017. Selective blood transfusion involved raising haemoglobin levels to approximately 100 g/L in patients with admission haemoglobin ≥10 g/L below steady state. There was no mortality. Mean post-operative stay was 3.2 days with a median of three days. Total morbidity was 19/150 cases (12.7%), with acute chest syndrome accounting for 11/19 (57.9%). Among the non-transfused, acute chest syndrome occurred in 10/117 cases (8.5%), while among transfused, acute chest syndrome occurred in 1/33 cases (2.9%). We recommend this selective blood transfusion protocol for patients with sickle cell disease to surgeons who undertake splenectomies in settings where blood bank reserves are perennially low.

Crimean–Congo haemorrhagic fever (CCHF) is a severe form of haemorrhagic fever identified in parts of Africa, Asia, Eastern Europe and the Middle East. CCHF continues to be a justifiable cause of concern for people in rural areas where the disease is endemic. A total of 151 patients, diagnosed with CCHF, were evaluated retrospectively. The demographic characteristics of these patients and the relationship between the neutrophil–lymphocyte ratio (NLR) at admission and survival were examined. There were 21 (13.9%) deaths. There was no relationship between age, gender and mortality, but elevated neutrophil–lymphocyte ratio (NLR) on admission was statistically associated with mortality. NLR is a laboratory marker that can be studied even in medical centres with limited facilities and may be helpful in predicting the clinical course of the disease.

Laparoscopy and antibiotic-first (NOM) strategies have been introduced in the management of acute appendicitis in industrialised countries. Data regarding the feasibility of these strategies in low-income nations are sparse. A retrospective analysis of adult patients undergoing appendicectomy at a county non-teaching hospital in San Benito, Guatemala (Hospital Nacional (HNSB)) was compared to an academic, teaching institution in Dallas, USA (Veterans Medical Centre). Most patients at the VA (92%) underwent computed tomography prior to being operated upon while none did so at HNSB. Whilst all patients at HNSB underwent an open approach, 95% of VA patients underwent a laparoscopic appendicectomy with a 4.7% conversion rate. General anaesthesia was universally used at Veterans Medical Centre, whilst spinal anaesthesia was utilised in 88% of cases at HNSB. NOM of acute appendicitis was undertaken only rarely at the Veterans Medical Centre and never at HNSB, where it was not thought expedient.

The aim of our study was to determine the incidence, microbiological profile, risk factors and outcomes of patients diagnosed with ventilator-associated events in our tertiary care hospital. In this prospective study, intensive care patients put on mechanical ventilation for >48 h were enrolled and monitored daily for ventilator-associated event according to Disease Centre Control guidelines. A ventilator-associated event developed in 33/250 (13.2%); its incidence was 3.5/100 mechanical ventilation days. The device utilisation rate was 0.86, 36.4% of patients had early and 63.6% late-onset ventilator-associated pneumonia whose most common causative pathogen was Acinetobacter sp. (63.6%). Various factors were significantly associated with a ventilator-associated event: male gender, COPD, smoking, >2 underlying diseases, chronic kidney disease and elevated acute physiological and chronic health evaluation II scores. Therefore, stringent implementation of infection control measures is necessary to control ventilator-associated pneumonia in critical care units.

Infections by soil-transmitted helminths are a major public health problem worldwide, especially among schoolchildren in low-income countries. Little information is described about their prevalence in the Solomon Islands. From 2017 to 2018, a school-based soil-transmitted helminths survey in the Guadalcanal Province was conducted. A total of 454 schoolchildren were selected; the Merthiolate–iodine–formaldehyde concentration and stain was used. The prevalence was 17% of one or more parasites, including hookworm (8.8%), Strongyloides stercoralis (5.7%), Ascaris lumbricoides (4.2%) and Trichuris trichiura (3.5%). STH infection was significantly correlated with parents' occupations, hand washing, shoe wearing as well as gastrointestinal symptoms. To prevent STH transmission for schoolchildren in the Solomon Islands completely, combined preventive strategies seem necessary.

Hookworm infection is a neglected parasitic disease. Direct wet mount is the usual method for the diagnosis of hookworm in Ethiopia, but its sensitivity is unsatisfactory. A cross-sectional study was therefore conducted from January to February 2018 among 192 study participants in Debre Elias district. Stool samples were processed by three methods: the prevalence of hookworm was 77.6%, 68.2% and 49.0% by Kato–Katz, formol ether sedimentation technique and direct wet mount, respectively. Direct wet mount had relatively low sensitivity (61.4%) compared to formol ether sedimentation technique (85.6%) and Kato–Katz (97.4%). The latter two compared well with the gold standard method with kappa values of κ = 0.94, κ = 0.71 and κ = 0.39, respectively, and are therefore recommended over against the direct wet mount technique in detecting hookworm.

As it is increasingly being reported from India, we carried out a prospective study of patients with culture-proven melioidosis from south India, examining clinical, laboratory features, epidemiological data, risk factors, treatments, outcomes at three and six months, and factors associated with mortality.

Between 2014 and 2018, 31 cases were identified. Diabetes (83.9%) and alcohol abuse (58.1%) were common risk factors. Musculoskeletal, skin and soft tissue manifestations together constituted 48.4% of presentations, while 29% had pneumonia. During the intensive phase, 74.2% received one of three recommended antibiotic regimes, but 51.6% did not receive continuation treatment. Pneumonia and lack of continuation treatment were independently associated with a high mortality of 25.8%. Hot spots for melioidosis exist in India, and there is considerable diversity of presentation, including skin, soft tissue, musculoskeletal and neurological involvement. High rates of bacteraemia are shown.

Prolonged indwelling of endoscopically placed biliary plastic stents may lead to complications. We conducted a retrospective analysis of patients who underwent endoscopic retrograde cholangio-pancreaticography (ERCP) at our centre in 2017 and were noted to have retained biliary plastic stents ( > 3 months after an index ERCP). A total of 127 patients had previously placed biliary plastic stents, out of which 45 (35.4%) were retained. The median age of the latter was 52 years (range = 22–79 years) with 27 (60%) patients being men. The median duration of the retained stents was 144 days (range = 94–3292 days). The majority of the patients were asymptomatic. However, 9 (20%) patients had cholangitis, 2 (4.4%) had choledocholithiasis, 2 (4.4%) had cholangitic abscess and 1 (2.2%) developed septicaemia. Fortunately, all these complications could be managed medically and endoscopically. Retention of biliary plastic stents is a problem often overlooked and underestimated in clinical practice. Various measures need to be instituted to create awareness of this entity to prevent undesirable outcomes.

Apart from its association with metabolic syndrome and diabetes mellitus, non-alcoholic fatty liver disease (NAFLD) has been thought to be linked with other endocrine and metabolic disorders. Recent data suggest that hypothyroidism may be a significant risk factor for development and progression of NAFLD. The present study was conducted to evaluate the presence of NAFLD in patients with hypothyroidism presenting to a rural tertiary care centre in north India. The diagnosis of NAFLD was made on the basis of radiological findings and derangement of liver enzymes. Our findings showed that ultrasonographic evidence of fatty liver as well as increase in the serum transaminase level above normal range were significantly higher in hypothyroidism patients as compared with controls. On multivariate regression analysis of the patients’ data, the presence of hypothyroidism was independently associated with risk of NAFLD. We therefore conclude that hypothyroidism is a significant independent risk factor.

We aimed to investigate 214 patients further with non-alcoholic fatty liver disease (NAFLD) as judged by transient elastography. A body mass index of ≥25 was seen in 172 (80%) of the patients. F2–F4 fibrosis, as depicted by elastography, was present in 114 (53.2%). A Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) of ≥2 was seen in 178 (83.2%). Alanine aminotransferase was elevated in 116 (54%) and aspartate aminotransferase in 88 (41.1%). Liver steatosis was significantly associated with increasing alanine aminotransferase, insulin, HOMA-IR and cholesterol levels. Regression analysis showed cholesterol as a factor independently associated with the degree of liver steatosis. The independent variable related to increasing liver elasticity was steatosis. In conclusion, a significant number of our patients with NAFLD had steatohepatitis and F2–F4 fibrosis.

We aimed to determine the clinical profile and outcome of Indian children with glycogen storage disorders. Ours was a retrospective study from 2005 to 2018 in 36 children diagnosed on the basis of a liver biopsy. Most (77.7%) presented with abdominal swelling but a quarter with convulsion, four of whom had documented hypoglycaemia associated, doll-like facies or developmental delay. Diarrhoea was found in four patients, ascites in two and portal hypertension in one. One child died, and over half were unfortunately lost to follow-up, though the rest had recurrent seizures, three more developed neutropenia, two recurrent infections, one portal hypertension with epistaxis, one nephrocalcinosis and liver adenoma. Liver function improved in six (37.5%) with normalisation of triglycerides, and four of serum transaminases.

Our study aimed to determine the prevalence of prior exposure to hepatitis A virus in Crohn’s disease patients, whose IgG antibody levels against hepatitis A virus were compared with age and sex-matched controls. All of the 41 cases with Crohn’s disease and 43 controls included in the study tested positive for IgG anti-hepatitis A virus antibody, with titres (38.8 IU/ml, 22–63.9; median, IQR) similar to those in controls (40.7 IU/ml, 17.3–66.7; p = 0.75). Environmental sanitation remains poor in India, despite reasonable economic gains as reflected by universal exposure to hepatitis A virus infection. Vaccination against hepatitis A may not be important in patients attending inflammatory bowel disease clinic, owing to natural immunity provided by prior infection. The observed rise in inflammatory bowel disease incidence seems to be increasing despite persistently poor environmental hygiene.

India’s National Viral Hepatitis Control Programme recommends screening outpatients for hepatitis B at tertiary care centres. We aimed to assess the yield of screening and reasons for refusal for testing. We included adult outpatients at a tertiary care centre, South India during September and October 2019. Participants’ willingness to be tested and the reasons for refusal were noted. Fingerstick blood sample was tested for HBsAg using rapid kit. Of a total of 700 participants, 157 (22%, 95% CI: 19.4–25.7%) were unwilling to be tested. Men were more unwilling (26%) compared to women (19%) (aPR 1.90 95% CI: 1.22–2.94; p = 0.004). ‘Lack of time’ was the most common reason reported for refusal (10%). Of 543 participants tested, 15 (2.8%, 95% CI: 1.6–4.5%) were positive for HBsAg. Similar studies from other regions in India are required for the estimation of yield of opportunistic approach.

Isolated pancreatic and peripancreatic nodal tuberculosis may mimic pancreatic malignancy and may result in unnecessary surgery. Being a treatable disease, it is desirable to diagnose this condition without a laparotomy. Pancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass if the patient is young, residing in endemic tuberculosis regions, or has had a history of tuberculosis. We report our experience with pancreatic tuberculosis. Over a period of 12 years, we have managed 16 such patients, of whom 10 were diagnosed preoperatively. In six, the diagnosis was only made after extensive surgery. All 16 patients received antitubercular drugs and were well at a median follow-up of 52 months. Although pancreatic tuberculosis can be diagnosed by modern image-guided biopsy in a fair number of patients, if a high index of suspicion is maintained, a laparotomy may still be unavoidable in a subset of patients.

Advances in diagnostic and therapeutic interventions have improved the survival of neonates with sacrococcygeal teratoma in richer countries. These changes have not yet taken place in resource-limited settings. A retrospective analysis of neonates with sacrococcygeal teratoma operated at our centre during 1997–2016 was performed. Among 44 neonates enrolled, prenatal diagnosis of sacrococcygeal teratoma was available in 25% of pregnancies. All babies except one were born vaginally. Associated congenital malformations were seen in 20% (9/44). Types of sacrococcygeal teratoma were classified as Altman type I in 12 (27.3%), 24 (54.5%) as type II, 6 (13.6%) as type III and 2 (4.5%) as type IV. Morphologically, 77% (34/44) neonates had cystic lesions. All patients were managed successfully by total excision. Histopathology confirmed mature teratoma in 43 (97.7%). After a 12-month follow-up, no recurrence was observed. An uneventful pregnancy, absence of associated congenital anomalies, cystic morphology and a mature histology are good prognostic factors.

Our cross-sectional study estimated the prevalence and clinical relevance of hypokalaemia among confirmed COVID-19 cases admitted in three hospitals in Bangkok during the early outbreak in Thailand. Of 36 patients, nine were in the hypokalaemia group (25%) and 27 in the normokalaemia group (75%). All cases were asymptomatic, and 94.4% had mild hypokalaemia. Hypokalaemia was found significantly earlier in the course of COVID-19 without evidence of significant extrarenal potassium loss. Body temperature and mean serum sodium in the hypokalaemia group tended to be higher than the normokalaemia group. Hypokalaemia and potentially higher serum sodium among COVID-19 patients were the remarkable findings. This issue warrants for further investigation.

In 2016, the World Health Organization adopted dolutegravir (DTG)-based antiretroviral therapy as an alternative first-line treatment of HIV after many clinical trials showed that it was more effective, better tolerated and more protective than efavirenz and boosted protease inhibitors against discontinuation of treatment from adverse drug reactions. However, there was concern that DTG would lead to increased rates of immune reconstitution inflammatory syndrome (IRIS), especially in the setting of late presentation to care. Three cases at the University Teaching Hospital in Lusaka, Zambia highlight this concern, especially in persons living with HIV (PLWH), resulting in tuberculosis (TB) co-infection.

In order to emphasise the importance of histopathology in the clinically unsuspected diagnosis of duodenal strongyloidiasis, we report six cases diagnosed on duodenal biopsies identified from the database over a period of 15 years, and clinical, endoscopic and histopathological findings were analysed retrospectively. Four were elderly males and the remainder young females. Only one patient had an underlying immunocompromised state. Three presented with cholestatic jaundice and simulated hepatobiliary malignancy. In all cases, endoscopy provided non-specific findings. Only one case showed a predominant eosinophilic infiltrate. Eggs, larvae and adult forms of strongyloides were seen in crypts and showed intense basophilic staining on HE stain. It is concluded that since mostly undetected clinically, duodenal biopsy serves as the first step in the diagnosis of strongyloidiasis. Hepatobiliary manifestations, though very infrequent, should raise the suspicion for strongyloidiasis and thus necessitate the need for duodenal biopsy.

Liver abscess in early infancy is uncommon, needs a high index of suspicion for diagnosis and carries a high mortality. It presents most frequently by a fulminant course, generalised sepsis and multiple metastatic abscesses. An underlying predisposing factor is usually attributed in nearly all cases reported to date. These include prematurity, low birth weight, umbilical catheterisation (UC), administration of hypertonic dextrose or total parenteral nutrition via UC, exchange transfusion, blood culture proven sepsis, necrotising enterocolitis, antecedent abdominal surgery, birth asphyxia, omphalitis and underlying immunodeficiency. We present three cases of early infantile liver abscesses without any identifiable predisposing factor despite extensive work-up to search for such. Early recognition and management led to a favourable outcome in all our patients.

Percutaneous catheter drainage is one way of treating large liver abscesses that are partially liquefied or have thick pus. Apart from discomfort, severe pain, inflammation or frank cellulitis at the insertion site, and sometimes catheter dislodgement, failure to retrieve a catheter is unusual. This may occur either due to fibrous tissue securing the catheter or when inspissated secretions prevent the catheter tip from straightening. N-acetyl cysteine is a mucolytic and exerts action in many parts of the body such as the mouth, throat and lungs. We report successful removal of a catheter stuck in the liver using this substance.

In Scrunb Typhus, hepatotoxicity is an important, yet understudied, manifestation. We reviewed studies on scrub typhus, published in the last five years (2014–2019), which evaluated its clinico-epidemiological factors in India, and concentrated on its hepatic involvement. Nine studies were found, and no Indian study exclusively evaluated hepatic dysfunction. Thus, comments from a few international studies were also included. We conclude that liver dysfunction in the form of elevated serum transaminase levels is a common manifestation of scrub typhus, which may herald progress to fulminant hepatic failure.

Syphilis is an increasingly common infectious disease caused by the bacterium Treponema pallidum. Atypical clinical presentations occur that may delay its diagnosis and treatment. Regional enlargement of lymph nodes is seen in both primary and secondary stages. Such lymph nodes very rarely become abscesses. Antibiotics should be administered in this situation; however, if this fails, the lymph nodes should be surgically excised.

Kawasaki disease is a common childhood vasculitis. Fever and lymphadenopathy, at times, are the only clinical presentation of Kawasaki disease, which mimics infectious lymphadenitis, especially, when other features are yet to evolve. In such a scenario, ultrasonography of cervical lymph nodes can help to differentiate Kawasaki disease lymphadenitis from infectious lymphadenitis. We present one such patient who was initially diagnosed as having bacterial lymphadenitis; however, ultrasonography of the neck lymph nodes showed typical imaging features described with Kawasaki disease lymphadenitis.

Orbital trauma is often associated with foreign bodies. Wooden foreign bodies pose an urgent need for removal owing to their reactive nature and the high risk for infection. Though visual prognosis depends on associated ocular trauma, in selected cases, excellent visual and cosmetic outcomes are possible. An 18-year-old woman presented to our trauma facility with a history of fall directly onto a wooden stick from a height. On examination, there was a large wooden foreign body in the left medial orbit, extending into the ethmoidal sinus as visualised on imaging. After administration of perioperative antibiotics, the foreign body was removed in toto using careful tissue dissection and the soft tissue was closed in layers. Postoperatively at six months, the vision in the left eye was 20/20 with mild ptosis. Early surgery, careful dissection of soft tissues and adequate infection prophylaxis can lead to good outcomes in such cases.

Haemolacria is a rare condition that usually occurs secondary to a hidden pathology. On rare occasions when no underlying cause may be found, it is called essential idiopathic haemolacria. Here the authors report a case of a 13-year-old girl presented to the ophthalmology emergency department with spontaneous bloody tears from both eyes for the past six months. There was associated bleeding from the ear. The rest of the systemic and ophthalmology examinations were within normal limits. She was investigated systemically to look for any underlying pathology; however, her blood investigations, radiological imaging and local examinations performed by the Otorhinolaryngology, Ophthalmology, Gynaecology and Internal Medicine departments were all normal. A final diagnosis of bilateral essential haemolacria was made.

Pneumomediastinum is not uncommon in paraquat poisoning and usually results from oesophageal perforation or alveolar rupture in fibrotic lung disease. However, the combined presentation of pneumomediastinum and pneumoperitoneum is a rarity. We recently managed a young patient with paraquat ingestion who developed spontaneous pneumomediastinum. His chest radiograph also showed free air under the right hemidiaphragm. This pneumoperitoneum caused no clinical symptom and resolved spontaneously within a few days without any surgical intervention.

Left superior vena cava is the commonest congenital anomaly of systemic venous return. We present the case of a newborn where left jugular venous placement of central venous catheter resulted in cannulation of the left superior vena cava.

Glyphosate is a commonly used non-selective herbicide in agriculture and aquafarms. Gastrointestinal, respiratory and cardiovascular symptoms are predominant manifestations of glyphosate poisoning. Cardiac dysfunction should be kept as a possibility in patients presenting with shock, and the treatment is mainly supportive. We present such a case.

Idiopathic systemic capillary leak syndrome (ISCLS) is a potentially fatal disorder characterised by ‘attacks’ of varying intensity of hypovolemic shock in association with haemoconcentration and hypoalbuminaemia. It is a disease of exclusion, and the severity of attacks may mimic sepsis at presentation. We report a case of a lady with recurrent attacks of ISCLS with at least two life-threatening episodes, having been treated elsewhere as a case of steroid insufficiency. The diagnosis is often challenging, and treatment of an acute episode involves the judicious use of fluids and vasopressors, as required. Prophylaxis to prevent further attacks is of varied success.

Amoebic liver abscess is the most common extra-intestinal manifestation of amoebiasis. It usually responds well to treatment with metronidazole together with drainage, if indicated. Uncommonly, the abscess may rupture into the pleura, peritoneum or pericardium, bile duct at its hilum, or produce septic emboli. We present a patient with two rare complications: venous thrombosis and jaundice secondary to bilhaemia.

Splenic abscess is a relatively uncommon condition, posing a diagnostic and therapeutic challenge for the treating physician. It occurs due to haematogenous spread from endocarditis or other septic foci, especially in immune-compromised individuals and diabetics. We describe an elderly male who presented with splenomegaly and low-grade fever with no predisposing factors. Examination revealed a tender splenomegaly. Ultrasonography (US) showed a hypoechoic area within the spleen from which guided aspiration of pus grew Staphylococcus aureus and Klebsiella pneumoniae. Percutaneous drainage and culture-based antibiotics failed to resolve the abscess, obligating surgical drainage. Intraoperative biopsy from the abscess wall was reported as splenic marginal lymphoma. This unusual presentation of lymphoma needs to be considered in splenic abscess without known risk factors.

Feeding jejunostomy is a simple and common procedure done for providing enteral nutrition. Though generally safe, complications like dislodgement, clogging and leaking are commonly reported with an incidence as high as 44%. Intussusception is however a much rarer complication which may have catastrophic results and often needs urgent surgical intervention. We describe a case of a patient who underwent robot-assisted minimal invasive oesophagectomy but developed an intestinal obstruction in the follow-up period.

The spectrum of dengue infection illness ranges from mildly symptomatic disease to severe forms of dengue haemorrhagic fever and dengue shock syndrome. Expanded dengue syndrome refers to unusual complications involving gastrointestinal, hepatic, neurological, pulmonary and renal systems. Subacute thyroiditis represents a very rare and under-recognised complication of dengue. We report a case of a 38-year-old female presenting with recurrent fever and throat pain following an episode of dengue. After detailed clinical examination, biochemical evaluation and imaging studies, a diagnosis of subacute thyroiditis complicating dengue was made. We discuss its clinical course and management in this report. Only four such cases have previously been reported in literature. Subacute thyroiditis may represent another rare facet of dengue expanded syndrome.

Emphysematous cystitis is an uncommon form of complicated urinary tract infection mostly caused by Gram-negative organisms in elderly, debilitated or immune-compromised patients. It has a varied spectrum of clinical manifestations ranging from asymptomatic to generalised sepsis. Radiological investigations such as conventional abdominal radiography and computed tomography are quintessential for diagnosis. Treatment with culture-specific antibiotics forms the mainstay of management. We present the case of an elderly patient who presented with gastric carcinoma and, during his stay, developed an unexplained fever with rapid clinical deterioration. Emphysematous cystitis was diagnosed radiologically, and urinalysis revealed Klebsiella pneumoniae. Culture-specific antibiotics were started after obtaining the culture report, and despite early and aggressive management, the patient succumbed to generalised septicaemia. Although Emphysematous cystitis is known to have lower mortality compared to other gas-forming infections of the urinary tract, high degrees of clinical suspicion and early management are of paramount importance in obtaining a favourable outcome.

Tuberous sclerosis complex is a common neurocutaneous disorder that predominantly affects the brain, skin, eyes, heart and kidneys. The management of tuberous sclerosis complex has been revolutionised with vigabatrin for spasms and everolimus for angiomyolipomas and seizures. We describe a 10-year-old girl with generalised tonic-clonic seizures whose diagnosis of tuberous sclerosis complex was made in view of the presence of a forehead plaque. Certain clinical pointers such as ashleaf macules, café-au-lait spots, shagreen patches and forehead plaques must therefore be looked for in a child with unprovoked seizures.

Connective tissue diseases and infections are amongst the causes for organising pneumonia. However, organising pneumonia preceding other connective tissue disease manifestations is rare. Mycobacterium tuberculosis is rarely associated with organising pneumonia. We report such a case. A 50-year-old diabetic male, a roadside shop keeper, a current smoker presented with fever, breathlessness, cough and weight loss for four months. Chest radiography demonstrated areas of consolidation with halo signs. Anti-nuclear antibody blot was positive for Scl-70 and Jo-1 suggestive of a syndrome of systemic sclerosis and polymyositis overlap. Fibre-optic bronchoscopy guided lung biopsy was suggestive of organising pneumonia, and broncho-alveolar lavage detected Mycobacterium tuberculosis. Mycobacterium tuberculosis should be investigated as an aetiology of organising pneumonia, as this may occur in unestablished cases of connective tissue disease even before clinical and radiological manifestations appear, as response can be achieved with anti-tuberculosis therapy alone, without additional use of systemic steroids.

Triple A syndrome is a rare autosomal recessive disorder characterised by alacrimia, achalasia and adrenal failure. It was first reported by Allgrove in 1978 and 100 cases have been reported worldwide. This case report concerns a 24-year-old woman who was referred for evaluation of dysphagia and was finally diagnosed as such a case. A high degree of suspicion enables all the components of this syndrome to be searched for, as early diagnosis can reduce the morbidity and mortality.

Caudal duplication syndrome is a rare and interesting entity with a reported prevalence of <1/100,000 births. Caudal duplication syndrome encompasses a diverse spectrum of anomalies primarily involving partial or complete duplication of organs comprising the gastrointestinal, genitourinary and distal neural tube systems. The term ‘caudal duplication syndrome’ was coined by Dominguez et al. in 1993, in a case series of six patients presenting with findings pertaining to duplication anomalies of genitourinary system, hindgut, lumbosacral spine and cord. We here report a unique case of caudal duplication presenting in late adolescence and briefly review the available literature on this rare abnormality.

Deep venous thrombosis is a common clinical problem with significant morbidity and mortality. Since the iconic publication by Virchow in 1856, which placed all known causes of deep venous thrombosis into three groups, namely venous stasis, vascular injury and hypercoagulability, numerous causes have been added to each category. This case report highlights the importance of an anatomical imaging study of the pelvis in cases of recurring, proximal deep venous thrombosis of the lower limb.

Osteogenesis imperfecta is characterised by low bone mineral density, bone fragility, fractures and deformity. We present five such children treated with intravenous pamidronate, which resulted in a decrease of fracture rate and increase in spinal bone mineral density.

Examining a well-stained slide in a systematic manner is the key to being a good pathologist. For a blood smear, it involves examining first at low power (40× or 100×) for broader details and then going on to high power (400×) for finer details, from the tail end to the body of the slide. The ‘tail end’ is the key to early diagnosis.

We are reporting an unusual case of cavitatory pulmonary mucormycosis in a patient with uncontrolled type 2 diabetes mellitus who was treated successfully. This is a unique case of pulmonary mucormycosis masquerading as cavitatory pulmonary disease. A 45-year-old female presented with fever, chest pain, cough and breathlessness. She was also found to have very high blood glucose due to previously undiagnosed diabetes. Diabetic ketoacidosis is the most common predisposing factor for mucormycosis. Our patient had uncontrolled diabetes and presented with bilateral cavitatory pulmonary lesions even in the absence of diabetic ketoacidosis. Appropriate investigations were ordered, and alternate causes of lung cavitation were diligently excluded. She was treated with amphotericin-B for three weeks followed by oral posaconazole for eight weeks with excellent outcome. A low threshold for detection as well as a differential of mucormycosis must be kept in immunocompromised patients presenting with cavitatory lung disease.