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March 1993, Volume 43, Issue 3

Case Reports


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

A SURVEY OF URINALYSIS IN HA2ARA POPULA­TION. Khan, M.H., Akbar, M., Khan, J.A., Shah, S.H. and Zakiruilah.J. Ayub Med. Coil., 1991;4:1-6.
Specimens of 24 hours urine of 8430 males and 3170 females, subjects of Hazara Division were collected from the districts of Abbottabad, Mansehra and Kohistan. Sterilized bottles containing toulol 2 ml/100 ml were used for the purpose. A proforma with details of age, sex, weight, general health, dietary habits and past illness was filled out and a physical examination conducted on each individual. Vogel’s colour scale was used to determine the urine colour, volume was measured by graduated cylinder, p11 by nitrazine indicator paper and specific gravity by Vogel’s urinometer. Albumin was estimated by sulphosalicylic acid, glucose by Benedicts test, bile salts by Hays test, bile pigments by Harrison’s test, acetone by Legal test and blood by Benzidine test. Microscopy was done on the residual precipitate after centrifuging the urine. Pale yellow colour was found in 90 percent of the specimens. Abnormal albumin was found in 369 samples, glucose in 205, acetone in 93, bile salts in 187, bile pigments in 164 and occult blood in 68 urine specimens. Leucocytes 6.3, RBC 6.5, epithelial cells 8.5, amorphous urates 12.2, calcium oxalates 10.3, uric acid 6.3, granular casts 0.13, hyaline casts 0.3 and cellular casts 0.18, were observed per 100 subjects. The inspection of urine, on aqueous solution containing nitrogenous and other solid waste products removed from the blood, is one of the oldest laboratory procedures being used in medicine today. The analysis of urine provides information not only of renal function but also of many other metabolic activities of the body. The survey results show a pattern of existing UTI by the presence of leukocytes in urine. Crystals along with RBC indicate renal or vesical calculi. Blood chemistry, culture tests and radiological examination support the diagnosis.
Fetomaternal haemorrhage (FMH) is known to occur after induced abortions. Medical termination of pregnancy (MTP) has been legalised in India which is usually carried out in the first trimester. A leak of fetal blood as low as 0.1 ml is enough to sensitize the mother and the Rh antigen has been demonstrated in 38 days old embryos. A study was conducted on 50 women undergoing MTP at the Safdar jang Hospital, New Delhi. The proce­dure was conducted by dilatation and suction evacua­tion. Samples of venous blood were taken before and 30 minutes after MTP. 2 ml was placed in a sterile vial with EDTA for acid elution test done by Kleihaver technique and 4 ml was for serum APP estimation by UBI Magiwel APP quantitative kit. The age range of the women was between 19 and 39 years, parity varied between 0 and 5, gestational age was from 6 to 13 weeks and the com­monest blood group was ‘B’ (40%) followed by ‘0’ (32%) and 3 women were Rh negative. Significant FMH was detected in 27 cases by serum APP levels and in 13 cases by Kleihaver method. The two techniques were compared for sensitivity and specificity and it was noted that arise in maternal AFP concentration was a more sensitive indicator. Period of gestation also had a significant influence on the incidence of FMH. As PMH was detected in a high number of MTP cases in the first trimester also, it is recommended that anti-D immunoglobulin prophylaxis should be routinely ad­ministered to all RH negative women undergoing the procedure.
COELIAC DISEASE COMPLICATED BY LYMPHOMA. Butt, J.A. and Haider, Q. J.Pak.Instit. Med. Sci., 1991;2:120-121.
A case of coeliac disease complicated by lymphoma is presented. The patient was a 28 year old male with chronic diarrhoea since one year. The watery stools 10-15 per day were accompanied with fever between 99°-101°F, chills, anorexia, cramping abdominal pain, bloating and flatulence. Undigested food particles were present in the stool and there was intolerance to wheat and milk products. Small bowel biopsy revealed villus atrophy with lymphocyte and plasma cell infiltration of the jejunalmucosa compatible with adult coeliac disease. A gluten free diet improved the symptoms and caused a gain in body weight of 4 kilogram. Dietary indiscretion lead to a relapse necessitating hospitalization. He was dehydrated, anaemic cachectic, anicteric with non-tender hepatomegaly and palpable tender small bowel loops in the supraumbilical region. The haemoglobin (89%) and serum potassium were low (3 meq%). Polymorpho nuclear leucocytosis (17000/mm2) was present with an elevated blood urea (45 mg%). All other relevant investigations were inconclusive including upper G.I. endoscopy and abdominal CT scan. A repeat small bowel biopsy revealed villus atrophy and intense infiltration of lamina propria with cells having large nuclei and scanty cytoplasm. Reticulin around the cells was increased and the picture was suggestive of malig­nant lymphoma of the small bowel. Patients with coeliac disease have a greater in­cidence of malignancy. Lymphoma as a complication is encountered equally in both sexes and the most striking feature is muscle weakness. In the presented case it was difficult to assess if the patient developed the lymphoma in the short period of 6 months after the initial diagnosis or the malignancy presented initially with symptoms suggestive of coeliac disease. It is generally advised to regard the diagnosis of coeliac disease first complicated later bylymphoma.
VAGINAL CALCULUS. Malik, Z.I. and Anwer, K. Tbe J. Surg. PIMS., 1992;324:57-58.
The case of an upper vaginal calculus in a 30 year old woman is presented. She came in with a history of occasional dull pain in both flanks and urinary incon­tinence since one year. She had undergone a vesico­vaginal fistula repair 2 years back prior to which she had a history of prolonged labour in a home delivery. The urine analysis showed sterile pyuria, Hb was 7.65 G/dl and the KUB revealed a large multi-layered opaque shadow in the region of the urinary bladder. The intravenous urography gave a picture of bilateral ureteric dilatation with early clubbing of the renal calyces. The diagnosis of a vesical calculus was made and preliminary cystoscopy performed under general anaesthesia. No calculus was seen in the bladder. A bulge was seen in the posterior wall indicating an extravcsical mass and the irrigating fluid was seen to flow out of the vagina. The vaginal examination caused the stone to be delivered as such and a small high placed vesico-vaginal fistula was noted on a subsequent cystoscopy. Repair at this stage was deferred. Stones form in the urinary tract due to a number of causes and foreign objects as non-absorbable sutures and retained swabs induce stone formation. They either act as a nidus or predispose to infection which again is a factor for calculus disease. Such stones are large and laminated. In the presented case, the stone was formed in a short period following the fistula repair and this along with its appearance was suggestive of retention of a foreign body. Confirmation was had when on breaking the stone remanants of surgical gauze were detected.

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