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November 1992, Volume 42, Issue 11

Case Reports


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

BLOOD TRANSFUSION REACTIONS IN CHILDREN. Iinran,M., Khan, F.M., All, A.J. Postgrad. Med. Instit., 1986; 1:7-11.
Untoward reactions in 350 patients given blood transfusions in the paediatric department of Postgraduate Medical Institute, Lady Reading Hospital, Peshawar are presented. There were 203 males and 147 females with ages between 2 months and 13 years. The maximum patients were in the 0-2 years group. Haemoglobin was estimated on admission and family donors were encouraged. Volume of blood for trans­fusion was calculated as 20 to 30cc per kg body weight for whole blood and 0-15 cc per kg body weight for packed cells. The largest number of transfusions were of group B followed by group A and 0. Necessary precautions for blood transfusion were implemented. The disease pattern in the cases was 106 cases of anaemias of infection, 85 thallasaemia, 58 malnutrition anaemia, 30 acute haemolytic crises, 13 haemophilia, 18 malignancy, 14 purpura and 26 had anaemia due to miscellaneous causes. The untoward reactions encountered included mild pyrexia in 30 cases, hyperpyrexia 30 cases, skin rash 9, pruritus 6 and haemolysis with jaundice 1 case. With the limited facilities in blood banking these transfusion reactions were not of a serious nature. To further avoid transmission of serious diseases as malaria, hepatitis, syphilis and AIDS, modern technology should be made available in all blood banks of hospitals.
All specimens submitted to the bacteriological laboratory of Khyber Medical College, Peshawar during the period 1982 to 1984 were subjected to a routine culture to isolate the organisms and to determine the effective antibiotic.
The culture was done on blood agar, MacConkey’s agar, chocolate tellurite plates and cooked meat medium. Incubation was at 37°C and examination after 18 hours and where necessary 36 hours. Blood culture was carried out by inoculating 5 ml of blood into 50 ml glucose broth. Subcultures were made on solid media. Antibiotic sensitivity tests were carried out by paper disc diffusion method. A total of 766 organisms were isolated, the largest number being from the urinary tract with esch coli predominating. The most effective antibacterial drug was norfioxacin with gentamycin, pipemedic acid and tobramycin following. There were 81 isolates of staph. aureus mostly from pus and tobramycin was the most effective drug followed by rifampicin and gentamycin. Pseudomonas aeruginosa was isolated from 62 specimens mostly from ear infec­tions and the most effective drug was tobramycin. Proteus vulgaris was found in 57 specimens with the most sensitive drug being pipemedic acid and tobramycin and gentamycin being next in order. Carbenicillin was the most effective drug against beta haemolytic streptococci. Antimicrobial resistance is a problem faced by every new antibiotic at some stage. A comparison of this study with a previous study carried out between 1977 and 1980 showed several changes in the isolates and their an­tibiograms. The number of infections with esch. coli had increased with a simultaneous rise in the number of isolates sensitive to gentamycin. Resistance to other antibiotics was much higher . Staph aureus isolates sensitive to most of the antibiotics was noted. An increased resistance to co.trimoxazole as found in other countries was also observed. Pseudomonas aeruginosa was seen to be more sensitive to tobramycin with gentamycin and carbenicillin showing resistance. Minocycline was the most effective tetracycline against esch. coli and can be considered to be the drug of choice especially in the renal failure cases.
UPPER GASTRO-INTESTINAL ENDOSCOPY. Shah, S. J. Postgrad. Med. Instit., 1986; 1:71-87.
Upper gastro-intestinal endoscopy was performed on 2834 patients in the gastroenterology department of Lady Reading Hospital, Peshawar. The male to female ratio was 1.5:1 with the majority patients being in the 4th to 6th decade. The main symptom was pain followed by haematemesis, dyspepsia and dysphagia. The results showed 917 cases having lesions in the upper G.I. tract with duodenal ulcer predominating. Oesophageal varices were the main cause of upper G.I. bleeding. The other pathologies noted were gastric cancer, gastric ulcer, duodenal diverticulum, hiatus hernia, oesophagitis, oesophageal carcinoma and erosive gastritis. Atrophic gastritis was not a common finding. The incidence of oesophagitis and oesophageal carcinoma was equal and snuff could be an attributing factor. All the gastric cancers diagnosed were of an advanced stage. Only 313 patients could undergo barium studies. The two procedures were correlated and it was noted that of the 79 barium studies reported normal, 37 had a positive lesion endoscopically. 234 studies had a report of an evident lesion. Of these 72 had a positive finding on endoscopic examination; 162 cases were negative. It was suggested that small particle barium sulphate to form a uniform paste and a simultaneous television screening procedure would have given more accurate results. Of the 2521 cases who did not undergo barium studies, 808 had definite lesions in the endoscopic examination. A specific correlation was found between duodenal ulcer and patients with an \\\'O\\\' positive blood group. Spicy food was found to be consumed by 307 patients of which 173 had some upper G.I. lesion and 91 had a duodenal ulcer. Smoking was a habit in 1800 cases of which 461 had no pathology in the upper G.I. tract. 902 patients had a duodenal ulcer followed by oesophageal varices, erosive gastritis and duodenitis. Modern endoscopy offers a direct view of the G.I. tract alongwith the advantage of photography of the lesion and multiple biopsies. It can be diagnostic or therapeutic as with electrosurgery, photocoagulation and scierotherapy. The blood group ‘0’ positive and smoking appear to have a direct relation with duodenal ulcer.
PENICILLAMINE ASSOCIATED MYASTHENIA PRESENTING AS RESPIRATORY FAILURE. Hafiz ul­lah, M., DelamLme,J.P., Packe, G.E., Clarke, C.W.F.J. Postgrad. Med. Instit., 1986; 1:115-117.
The case report of a patient suffering from rheumatoid arthritis on penicillamine therapy and having developed a myasthenic syndrome is presented. The 52 year old female with a five year history of classical ,rheumatoid arthritis was started on penicil. lamine. After a period of 8 months she was hospitalized with severe breathlessness. She was on penicillamine 750 mg daily, prednisolone 14 mg daily and chioroquin 250 mg daily. On examination she was tachypnoec with generalized muscle weakness mostly involving the exten­sors of the neck. Systemic examination was unremark­able. The x-ray chest, ECG, haemogram and blood biochemistry were normal. The respiratory effort deteriorated with the passage of time and the blood gas analysis confirmed respiratory failure. Mechanical ven­tilation was commenced. Edrophonium and neostigmine tests were negative. Electromyography and muscle biopsy gave no evidence of myopathy. A ch R antibodies and stricated muscle antibodies were present which supported the diagnosis of penicillanune associated myasthenia. Pyridostigmine 300 mg daily and prednisolone 40 mg daily were administered and mechanical ventilation could be stopped after 19 days. Plasma exchange was carried out for 5 days due to the persistent weakness. A ch R antibodies were undetectable, after the procedure but they reappeared after a month and then a gradual fall In titre was observed in the following 8 months. Muscle strength returned to the pre-iliness level. Presence of A ch R antibodies in a patient with severe muscle weakness is a strong indication of drug induced myasthenia. Respiratory failure as the present­ing feature is rare in idiopathic myasthenia. Absent ocular symptoms, no clinical response to anticholinesterase agents and clinical improvement after plasma exchange, all indicate penicillamine associated or idiopathic myas­thenia.

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