Indian Journal of Emergency Medicine

 Myocardial Infarction rarely occurs in a patient with a recent normal Treadmill Test [1]. The case presented in this study describes a 54 year old male Indian who presented with an acute myocardial infarction in spite of having a normal treadmill test, normal electrocardiogram and relevant blood tests. The conclusion drawn from this study is that treadmill tests though very important for cardiological evaluation, a negative test does not rule out an underlying Coronary Artery Disease.

Keywords: Myocardial Infarction; Electrocardiogram; Coronary Artery Disease.

 Foreign body inhalation in children is a serious condition which may leads to acute respiratory distress, lung injury or death. The diagnosis of foreign body aspiration requires a high index of suspicion because the diagnosis is often not obvious. This article presents a case of 3 year old girl presented to emergency with cardio-pulmonary arrest due to foreign body (Balloon ) aspiration and revived after timely intervention.

Keywords: Balloon; Cyanosis; Foreign Body Aspiration; Cardio-Pulmonary Resuscitation (CPR).

 Dropped head syndrome (DHS) is known entity and has multiple causes. Dropped head syndrome has been reported both in hypokalemia secondary to several causes and in hypothyroidism as such. But its association with hypothyroidism and hypokalemia has not been reported so far. We present a case of DHS associated with hypothyroidism and hypokalemia. A 35-years-woman presented with dropped head syndrome. Biochemical evaluation revealed hypokalemia and hypothyroidism. Other causes of hypokalemia have been ruled out. The patient responded well to intravenous potassium initially but after institution of thyroxine potassium again started falling down. Therefore oral potassium chloride was continued in small doses for next four weeks. At end of six weeks, her TSH normalized and potassium was maintained in normal range without replacement.

Keywords: Dropped Head Syndrome; Hypothyroidism; Hypokalemia.

 Guillain-Barre Syndrome (GBS) is a immune mediated peripheral nerve myelin sheath destruction usually presented with bilateral lower extremity pain, worsening dysphagia, subsequent ascending symmetric weakness, and loss of deep tendon reflexes. The diagnosis is usually made based on the signs and symptoms, through the exclusion of alternative causes, and supported by tests such as nerve conduction

 Post seizure epilepsy imposes a clinical dilemma in terms of diagnosis and management. Standard mortality rate for epilepsy related to CVA is higher than for all other causes. Effect of post stroke seizures on stroke outcome remains unclear. We present a case report of unusual presentation of CVA as “epilepsy partialis continuum”. More research about specific health related quality of life and measures relevant to post stroke epilepsy is needed for better understanding and optimal management of this clinical condition.

Keywords: Stroke; Arterial Ischemic Stroke; Epilepsy; Hemorrhagic Stroke; Antithrombotic Therapies.

 Meningitis, when caused by the fungal mycoses Cryptococcus neoformans, is normally seen in immunocompromised hosts. However, immunocompetent patients are also susceptible to cryptococcal meningitis (CM). In patients with an intact immune system, CM usually presents with the typical signs and symptoms of meningitis: fever, stiff neck, and headache. Although a recognized cause of meningitis in the immunocompromised patients, the incidence of CM has been on the rise in immunocompetent hosts as well with early diagnosis and adequate treatment greatly reducing the morbidity and disease progression.

 Despite the progress in the laboratory detection of acute myocardial infarction (AMI), medical history remains the most important diagnostic step in order to establish the diagnosis. Most patients with AMI describe a severe, pressure-type pain in the mid-sternum, often radiating to the left arm, neck or jaw. The pain resembles angina, but it can be distinguished from it by its intensity, duration (>30 min), and failure to resolve with nitroglycerin administration. The pain may also be accompanied by nausea, vomiting and diarrhea, especially when the infarction is located in the inferior wall. Other symptoms include dyspnea, diaphoresis, dizziness, palpitations, cold perspiration, profound weakness and syncope. The diagnosis of AMI may be difficult when atypical symptoms occur, such as indigestion, unusual localization of the pain, agitation and altered mental status. Furthermore, AMI may be silent in more than 25% of cases, in which the infarction is not recognized by the patient and evidence of the infarction is provided by the electrocardiogram or post-mortem examination. Asymptomatic infarction occurs more frequently in elderly patients with hypertension, angina pectoris, and, mostly, diabetes mellitus, as a result of the polyneuropathy that accompanies long-standing and uncontrolled diabetes. We describe here a case which presented to ED with severe headache accompanied with nausea, vertigo. During routine investigation, ECG was done which showed ST elevation in lead II,III, AVF and showed marked ST-segment depression in leads V1 to V5 and slight ST-segment depression in leads I and aVL. So headache was the sole symptom of AMI which was very rare. 

Keywords: Myocardial Infarction; Headache; Vertigo; Chest Pain; Nausea.

 Subcutaneous manifestations of acute pancreatitis have been mentioned in reference texts with Grey turner’s sign and Cullen’s sign being the most prominent amongst others like Fox’s sign and Walzel’s sign.Inspite of exhaustive reference of these signs many physicians have not seen the representative cases and at times are not able to appreciate them. Grey turners sign is produced by spread of liberated pancreatic enzymes from the anterior para renal space between the two leaves of posterior renal fascia and subsequently to the lateral edge of quadratus lumborum. The prevalence of this sign has been mentioned as 3% in previous studies with mortality rate of 37% amongst patients with positive sign. The submitted case report highlights the typical presentation of acute pancreatitis manifesting Grey turner’s sign. The skin sign of acute pancreatitis are rare but if present they confer a poor prognosis, henceforth recognising such patients with severe acute pancreatitis as soon as possible is critical for achieving optimal outcomes. 

 Thrombotic thrombocytopenic purpura (TTP) refers to the disorder of widespread microvascular thrombosis involving the capillaries and arterioles of the brain and other organs. The incidence of TTP is about 4-5 cases per million people per year. TTP has long been recognized as a complex and life-threatening disease. Without treatment, TTP undertakes a rapid course of deterioration. Plasma exchange or infusion is the mainstay of treatment for TTP. In recent years, our understanding of the basic biochemistry of the VWFADAMTS13 axis has provided valuable insights into the pathogenesis of TTP, as well as the investigation and development of new therapeutic strategies. Although the mortality associated with TTP has been appreciably reduced, much yet remains to be learned to more effectively treat and better understand this disease. The authors take the opportunity to present the case report of a young female with varied signs and symptoms,diagnosed as TTP. The rapidly progressive and fatal course of the acute illness explains the need for considering TTP as a probable diagnosis in ED in a patient with fever with purpura and thrombocytopenia.

Keywords: TTP; Adamts-13; VWF; Coagulopathy.

 Miller Fisher syndrome (MFS) is seen in about 1-5% of all cases of Gullain Barre syndrome. MFS is characterized by a classic triad of Ophthalmoplegia, Ataxia and Areflexia. Additional symptoms include bulbar palsy, motor weakness and sensory loss. However, ophthalmoplegia is the most important and consistent finding in this syndrome. The incidence in males and females is 2:1 and the mean age of presentation is around 43 years. The anti-GQ1b IgG antibody is found in about 90% of MFS cases and it is a very specific and a sensitive marker. We are presenting a case of Miller Fisher syndrome which manifested with ophthalmoplegia, hyporeflexia and ataxia with proptosis and chemosis in a 50 yrs old male.

Keywords: Gullain Barre Syndrome; Miller Fisher Syndrome; Ophthalmoplegia; Ataxia; Areflexia; Proptosis; Chemosis; GQ1b Antibody; IV Immunoglobulin.

 Guillain-Barré syndrome (GBS) is an acute fulminant polyradiculoneuropathy that is autoimmune in nature. It manifests as a rapidly evolving areflexic motor paralysis with or without sensory disturbance. Weakness typically evolves over hours to a few days and is frequently accompanied by tingling dysesthesias in the extremities. Approximately 70% of cases of GBS occur 1-3 weeks after an acute infectious process. Although GBS is considered to be monophasic, recurrences are reported in 2–5% of patients [1,2]. We describe a case of 20 year old male who presented with ascending limb weakness along with difficulty in swallowing and speaking since 12 hours. He further developed respiratory failure requiring mechanical ventilator support and was diagnosed as a case of Guillain-Barre syndrome. Patient had history of similar episode 15 years back for which he was hospitalized for 4 months and had complete recovery.

Keywords: Ascending Weakness; Immune Response; Peripheral Neuropathy; Respiratory Failure; Recurrent Guillain-Barre Syndrome.

 A 3 years old boy presented with h/o fever, gross hematuria and vomiting after ingesting some locally popular ayurvedic drug formulation called GERU which contains Ferric oxide. On investigations he was found to be G6PD deficient which lead to Intravascular hemolysis and Methemoglobinemia. He was aggressively and conservatively managed in a Paediatrics ICU and was discharged in stable condition after 5 days.

Keywords: G6PD Deficiency; Intravascular Hemolysis; Hemoglobinuria; Methemoglobinemia; Geru; Hematite; Toxicity; Ayurvedic Medication; Ferric Oxide; Hypoxia; Forced Alkaline Diuresis; Saturation Gap; Methylene Blue.

 Posterior reversible encephalopathy syndrome (PRES) is a reversible neurotoxic state that occurs secondary to the inability of posterior circulation to auto-regulate in response to acute changes in blood pressure. It is characterized by seizure, headaches, visual symptoms, impaired consciousness and other focal neurological findings. It is coupled with a unique CT or MR imaging appearance. Recurrent PRES has been reported in severe hypertension and after allo-BMT [1,2]. In a recent reported series, recurrent PRES was noted in 3.8% of patients [3]. We describe a case of 62 year old woman with chronic obstructive pulmonary disease and hypertension who presented with two days history of blurring of vision, altered sensorium, headache and developed 2 episodes of generalized tonic clonic seizures after coming to hospital. On MRI Brain, hyper intense lesions seen in the bilateral parieto-occipital lobes with diffusion restriction, suggesting possibility of Posterior Reversible Encephalopathy Syndrome. Patient had history of similar episode 17 months back. CECT brain done at that time had features persistent with Posterior Reversible Encephalopathy Syndrome.

Keywords: Posterior Reversible Encephalopathy Syndrome; Hypertension; Seizure; Recurrent PRES; Hypertensive Encephalopathy.

 Dengue is one of the leading causes of mortality amongst seasonal arboviral diseases in the Indian subcontinent. The Clinical manifestations of dengue vary from mild febrile illness to life threatening dengue shock syndrome with polyserositis and severe hemorrhagic tendencies. There is also a variability in presentation in different areas of endemicity and between specific age groups. whereas predictors of outcome have remained controversial. To understand the antibody responses to dengue nonstructural 1 (NS1) glycoprotein and its role in protective immunity or pathogenesis of dengue fever (DF) and dengue hemorrhagic fever (DHF), we have analysed the NS1-specific IgM, from patients with DF and DHF. The morbidity and mortality of DHF can be reduced by early hospitalization and careful supportive care. Circulating NS1 has been detected in acute-phase serum samples of patients with DV infections. The goals of this study were to determine whether plasma levels of NS1 correlate with severity of dengue in terms of shock, hemorrhagic manifestations, polyserositis, ARDS, need of intensive care and duration of hospital stay. In addition to the end result in terms of Mortality and residual disability.

Keywords: Antigen; Fever; Hypotension; Shock; Serology.

 Abdominal pain is one of the common complaints encountered in the emergency. On an average, 6.8% of the patients present to the ER with complain of pain abdomen. Considering the busy ED environment, limited resources and the need for attending to an impending doom of clinical scenarios ranging from mild itch to life threatening injuries, it might not be easy for any emergency physician to look for what an abdomen is hiding as it has aptly been called as the Pandora’s box. The authors conducted a retrospective observational study in the emergency department where in patients presenting with abdominal pain where prospectively followed through the course of ED and hospital stay. On the basis of patients parameters like presenting complaints, severity and duration of symptoms, physicians attending time, diagnostic working modalities and final outcome in terms of symptom relief, underlying pathology, need for surgical or other interventional procedures. The management of pain abdomen in the emergency department is now taking a lead in coherence of provisional diagnosis and final diagnosis with trained personnel in emergency. 

 Background: Burn trauma is one of the common problems seen in emergency department in tertiary care hospitals of Kolkata. Very few papers has been published in India regarding burn trauma, where as Burn trauma is quite frequent in India. Incidences vary from region to region and among different socio-economic groups. It has been observed that proper care of burn patient often hampered due to lack of infrastructure, trained professionals etc. In India there are very few hospitals with separate burn units, hence most of the burn patients are being managed by staff without any proper training in burn care. Aims and Objectives: To identify demographic and socio-cultural factors, type, modes, causes and risk factors for burn injuries and their age and gender-wise association. Material and Method: It was a retrospective study done on all burn patients presenting to the emergency department of Peerless Hospital and B. K. Roy Research Center from January 2014 to December 2015. The data was collected from the hospital records section. A total of eleven parameters were recorded on excel sheet and then analyzed by the statistician. Result: Total 56 burn patients presented during my study period. Among them 25% had first degree burn, 19.64% had second degree burn and 55.36% had third degree burn. The mode of burn was found to be Thermal in 80.36% patients, Chemical burn in 5.36% and Electrical burn 14.29%. The mechanism of burn was accidental in 98.21% and suicidal in 1.79%. No micro-organism was isolated in 96.43% 0f the patients. 82.14% patients received surgical management whereas 17.86% were managed conservatively. Among the total 56 patients 50% were discharged home whereas 32.14% left against medical advice (LAMA). Death occurred in 17.86% of patients. Conclusion: Majority of the burns occur in female population with peak age between 26 to 40 years. The highest incidence occurred due to accidental thermal injury. An education program is needed to make the population aware of various etiological factors causing burns and their prevention. Safer means and practices should be adopted in kitchen. Local health care facility should play a major and proactive role in managing burns.

Keywords: Burn; Thermal; Accidental; Female; Prevention.

 Background: It is very important to identify the local bacterial population and their antibiotic sensitivity pattern. This study aims at finding out local bacteria causing positive blood cultures in neonatal sepsis. Objective: To identify the pattern of growth of micro organisms in the blood culture in patients of neonatal sepsis in a tertiary care centre of India. Material and Method: A prospective randomised study was carried out in the Emergency Department of Peerless Hospital and B K Roy Research Centre Kolkata, India for one year (01/07/2013 to 31/06/2014) results: A total of 30 samples were found positive where This study shows that klebsiella.p and candida is the most common organism causing sepsis in maximum type of samples of neonates in this tertiary care centre of Eastern India. For Klebsiella.sp the first choice of antibiotics should be amikacin, colistin, tigecycline. And second choice should be Cefepime and Carbapenams. For Candida sp the first choice of antibiotics should be Voriconazole and Flucytocin. Second choice should be Fluconazole and Amphotericin B. Staph was most sensitive to Linezolid(100%), Tigecycline (100%), and Vancomycin(100%) Enterobacter(20%) is most sensitive to Colistin and Tigecyclin(100%) ,than Amikacin, Cefepime, Cefoperazone and Sulbactum,Piptaz and Meropenam all 50% sensitive. Conclusions: This study paves a path for future studies to occur.

Keywords: Neonate; Blood Culture; Sepsis.

 Background: Acute gastroenteritis is a common problem in developing countries like India. The most common complication of acute diarrhoea is dehydration leading to hypovolemia and further complications like acute kidney injury or acute renal failure due to loss of fluid and electrolytes and antimicrobials injury. Acute renal failure occurs due to quick volume depletion in diarrhoea and is even accelerated in the hot environment. Acute renal failure secondary to acute gastroenteritis is still a common problem in our country. So early referral and adequate replacement of fluid and electrolytes and antimicrobials can improve outcome in these patients. Aims and objectives: To find out the following: 1. Percentage of acute kidney injury in diarrhoea patients. 2. Associated conditions leading to increased acute kidney injury in diarrhoea patient. 3. Outcome of acute kidney injury in patients with diarrhoea. 4. Secondary aim of the study is to evaluate the adequacy of the treatment. Material and Methods: Patient parameters, like the time from the onset and time of attending the hospital, severity of diarrhoea, stool culture report (to identify causative organism) will be collected by the primary investigator. Associated factors like age, sex, co morbidities like Hypertension, Diabetes will be looked upon to link the percentage of occurrence relation with these factors. Creatinine will be evaluated at the time of admission and again reevaluated after 48 hours. Patients with an increased serum Creatinine will be evaluated by the KDIGO criteria to be diagnosed as Acute Kidney injury. The percentage of patients developing acute kidney injury and started on treatment was regularly observed during their hospital stay by the principal researcher. Results and Discussion: It was noted that the incidence of acute kidney injury is 22% in the study which is pretty significant. The number of deaths that occurred during the study is only 2%. It was seen that earlier referral to a tertiary care hospital and timely replacement of fluids can decrease incidence of renal failure.

Keywords: Gastroenteritis; Acute Renal Failure.