November 1996, Volume 46, Issue 11

Review Articles

Abstracts from the Journals of the East

Fatema Jawad  ( 7/6, Rimpa Plaza, MA. Jinnah Road, Karachi. )

Rickets in a Slum of Karachi. Jamal A., Khanani, M.R., Billo, G., Asghar, A., Jafri, Z., Specialist, Pak. J. Med. Sci., 1996;12:247-250.
Eighty children, 50 males and 30 females, suffering from rickets were studied to determine the etiological factors, clinical presentation and response to treatment. All the children belonged to New Karachi; an under-developed area at the out-skirts of the city. People living here belong to the lower socio-economic strata and have little knowledge of nutrition, hygiene and sanitation. The children included in the study had skeletal deformities and rickets was confirmed by a wrist X-ray showing cupping, fraying and osteoporosis and raised serum alkaline phosphatase. Questions were asked about the development of the mile stones, frequency of motions, respiratory tract infection, pain in legs with difficulty in walking. Clinical examination included measurement of height and weight and assessment of the nutritional status according to the Gomez classification Laboratory investiga­tions performed were serum calcium, phosphorus, alkaline phosphatase and stool examination in diarrhoea cases. Wrist X-ray and of the long bones when indicated were also carried out. Vitamin D3, 6 lacs were given intragluteally to all children once a month. In giardia cases metronidazole was adrninis­tered in the required dose. Confirmed coeliac disease subjects received a gluten free diet. Monthly follow-up was done and those children showing no response in 3 months were classed as non-deficiency rickets and investigated further and treated with alfacaicidol. All cases were followed upto 24 months. Of the 80 children, 74 were below 4 years age. Nutritional assessment revealed 46 patients with grade III PEM, 24 with grade II and 10 with grade IPEM. Biochemical and radiologi­cal evidence of rickets was found in 44 cases, 36 had raised alkaline phosphatase, 44 had giardiasis and 2 coeliac disease.
Of the 74 children in the less than 4 years age group, 73 had deficiency rickets. Of the remaining 6 from the entire study group 4 were vitamin D resistant. Al! the 80 cases responded well to their respective therapies in a period of 6 to 24 months. It was concluded from the study that to prevent rickets, mothers need to be educated. Child spacing should be encouraged and health care workers should be trained to recognise rickets at an early stage and provide appropriate treatment. Vitamin D3 supplements should be administered to all children in the age range 6 months to 2 years, living in slum areas.
Mycobacteriu Fortuitum Brain Abscess: A Case Re­port. Ahmad I., Hussain, S., Shafi, M., Siddiqui, S., Pak J.Pathol., 1995;6:73-75.
The case of a 40 years old male diagnosed as brain abscess caused by mycobacterium fortuitum is presented. The presenting complaints were multiple skin abscesses, progres­sively increasing weakness of the light side of the body, involuntary jerky movements of the right arm and leg and weight loss, all ranging from 3 to 9 months. There was no history of diabetes or hypertension and he had received antitubercular therapy for pulmonary tuberculosis 14 years earlier and lately for the present problem.
The laboratory tests showed a haemoglobin varying between 7 and 13G/dl, total leucocyte count between 9,550 and 18,800/cmm and an ESR of 125mm in first hour. HIV antibodies were negative. Routine culture of the pus gave no bacterial growth. The CT scan of the brain revealed multiple space occupying lesions. Surgery was undertaken and a large brain abscess removed. Besides the routine staining Ziehi­Neelsen stain was used on the histopathological sections. Acid fast bacilli were identified. Culture was performed on Lowen­stein-Jensen medium which grew acid fast bacilli. Identifica­ tion to species level by standard methods gave a diagnosis of mycobacterium fortuitum. The antimicrobial sensitivity of the isolate gave a sensitivity to a number of antibiotics with the most active agent being Amikacin. The patient was put on Amikacin and co-trimoxazole for 4 to 6 weeks. Brain abscess due to mycobacterium tuberculosis is commonly encountered. M. fortuitum which is an atypical bacteria has been seen to cause severe infections in immuno­compromised subjects especially in patients with AIDS.
In the presented case, apparently the primary skin infection lead to a haematogenous spread and a brain abscess. It was concluded that any chronic resistant skin abscess not responding to the routine antibiotics should be tested for atypical mycobacterium and treated in accordance to the sensitivity antibiogram. These organisms are usually resistant to antituberculosis drugs.
Leiomyosarcoma of the Rectum: A series of Twelve Cases. Wang, H.S., (hen, W.S,,Lin, T.C., Lin,J.K,Hsu, H., Chin.Med.,J. (Taipei), 1996;57:280-283,
Twelve patients (10 men and 2 women, mean age 54.4 years) diagnosed as rectal leiomvosarcoma and treated at Veterans General Hospital, Taipei. were retrospectively stud­ied. The most common symptoms were bloody stools and perianal pain. Lower rectum (4cm above the dentate line) was the location of 75 percent tumours Five patients were subjected to abdomino- perineal resection, 4 had wide local excision and 3 had diversion colostomy. Adjuvant therapy as radio or chemotherapy as given in 4 cases.
The overall 5 year survival rate was 46 percent and one year being 83 percent. Liver metastasis was present in 6 patients and lung metastasis in one case. Local recurrence of the tumour occurred in 3 of the 4 patients who had undergone wide local excision. Only one case with abdominoperineal resection had recurrence.
Abdominoperineal resection is the surgery off choice for patients with operable rectal leiomyosarcoma Wide local excision is recommended for those cases not suitable for radical surgery. Adjuvant therapy does not give the desired results and diversion colostomy is a palliative therapy.
Basic Haematological Derangements in Heroin Addicts. Zeb, J., Tayyab, M., Khan, H., Qure.shi, S.A., Lali, S.M., Hussain, S.S., Pak.J.Med.Res., 1995;34: 194-196.
To determine the baematological derangements in heroin addicts, a study was conducted on 90 male addicts selected from three hospitals of Lahore and Peshawar. The control group comprised of 30 healthy non-addicted individu­als who matched for age, sex and socio-economic status with the study group. Haemoglobin level, total leucocyte count, differential count and ESR were performed by standard methods. The haemoglobin level in addicts was 11.60 against 14.00 in controls. All except rwo of the former group had normocytic, normochmmic anaemia. Two addicts who had been selling blood had a Hb of 5.8 and 5.2G and were diagnosed as hypochromic microcytic anaemia.
The mean TLC in addicts was 8656x109/l and that in controls was 7363x109. There was no significant difference in the differential count. The ESR in addicts was much higher (mean 21.Omrn/Ist hr) than the controls (3 .Omrn/lst hr). The subjects belonging to the addicted population are malnourished living in unhygienic surroundings and being affected with malaria, hepatitis, tuberculosis and pneumonia. Of the 90 heroin addicts studied, 47 had pulmonaty involve­ment with 3 having tuberculosis and malnutrition was found in 30 individuals. These factors could be a probable cause of anaemia. The raised ESR and leucocytosis were the results of infection. Autoinimune anaemia encountered in HIV infec­tion inthe West was not found in this study. The reason for high HIV infection in that part of the world is the use of intravenous route to administer drugs by addicts.

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