October 1990, Volume 40, Issue 10

Case Reports


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

CLINICO-PAThOLOGIC STUDY OFCHOLELITHIASIS. Hanteed, M., Tayyab, M., flan, H. Pak. J. Med. Res., 1989; 28:194-198.
A study was conducted to evaluate the relationship of age, sex, parity, obesity and clinical signs and symptoms with cholelithiasis. 87 subjects were selected for the study of which 47 were patients of cholelithiasis and 40 were normal con­trols. Selection was made initially on the signs and symptoms of fullness or bloating in the epigastrium, intolerance to fatty meals, pain and tenderness in the right hypochondrium. Ultrasonography and cholecystogram was employed to confirm the diagnosis or to rule out the presence of stones. Age, sex, height, weight and parity were recorded. Obesity was considered when the body weight was 10 percent more than the desirable weight. The mean age of the stone formers was 42.6 years and the controls had an average age of 45.3 years. Females had the peak of disease at 40-49 years and in males the maximum incidence of gall stones was found in the age range of 50-59 years. Majority of the stone formers had five pregnancies whereas the controls had 2-4 pregnancies. 72.3 percent of the stone formers were obese as compared to 30 percent of the controls. Subjects with cholelithiasis had a history of biliary colic, tenderness in right hypochondrium and a palpable gall bladder. Flatulence, dull upper abdominal pain, intolerance to fattx food, nausea and vomiting were present in majority of the stone formers and in a few controls. It was determined that cholelithiasis occurred at a younger age group when compared to Western countries. This could be attributed to the higher number of pregnan­cies, obesity and lack of exercise. The female to male ratio in the present study was found to be 8.4:1. This declined with advancing age. Oestrogens and progesterones are both held responsible for the high incidence of cholelithiasis in females. Oestrogen exerts alithogenic effect whereas progesterone impairs gall bladder emptying. Multiparity was another related factor. Gall bladder emptying is impaired in early pregnancy and this increases progressively with each pregnancy. Obesity was found to be associated with gall stones. It has been observed that supersaturated bile is produced in obese subjects which predisposes to cholelithiasis. Reducing the number of pregnancies and controlling weight by a balanced diet and exercise could markedly reduce the incidence of cholelithiasis in this part of the world.
NUTRITION AND ACUTE RESPIRATORY INFECTION (AR!). Khan, J.A., Aziz, F., Rizwanullah. Pak. J. Med. Res., 1989; 28: 199-201.
A study was conducted to determine the impact of malnutrition on AR! morbidity and mortality in children under 5 years of age in district Abbottabad. 760 children below 5 years age in 600 selected households were followed for 2 years. Data was collected on the socio-economic conditions, nutritional status and ART related illness. 22 percent of the babies had a normal nutrition, 54% had mild, 17% moderate and 7% severe malnutrition. The results compiled indicated that mal­nutrition did not correlate with increased overall in­cidence of AR!. it was also noted that severely mal­nourished children had severe complicated acute lower respiratory infections and had to be hospitalized. Also case fatality rate was very high in children with third degree malnutrition. This pilot study concluded that poor housing facilities and poor nutrition has an increased ALRI fatality. An increased fatality due to ART was also observed in malnourished children. An intensified nutritional education programme would provide an important step in the control of ART. A CASE OF A RARE LUMP IN THE BREAST Jafri, S. Pak. J. Med. Res., 1989; 28: 218-219. A 50 year old female was admitted in Sir Ganga Ram Hospital, Lahore with a history of a painless, gradually increasing lump in the left breast since one year. On examination a lump of the size 4 x 3 cm was palpable in the lower inner quadrant of the left breast. It was indolent, with well defined margins, smooth surface and was freely mobile. Excision biopsywas done under general anaesthesia. On exposure the mass was found to be cystic with a thick white and laminated wall. The histology report confirmed the diagnosis of a Hydatid cyst. The haemagglutination test for echinococ­cus was positive till tin 200. As no other site of the cyst was found the case was labelled as primary hydatid cyst of the breast. Hydatid cyst of the breast is a rare occurrence. It is difficult to diagnose due to its location. X-ray chest is helpful in pulmonary cysts. Ultrasonography aids in locat­ing abdominal cysts and CT Scan is especially useful in intracranial cysts. Casoni\'s test and Hydatid complement protein test are positive in 80 percent cases. Mammography deter­mines the nature of the lump. A cystic mass should always arouse the sUspicion of Hydatid cyst. Treatment of the Hydatid cyst of thebreast is excision after aspiration to prevent spillage. Regular follow up is necessary as a recurrence would give a cause to consider mastectomy. Mebendazole tablets for 16 weeks are often given prophylactically.
USEFULNESS OF GARLIC IN THE TREATMENT OF LUPUS VUL­GARIS. Sami, A.S., Sami, A.R. Pak. J. Med. Res., 1989; 28:212-217.
Three cases of Lupus Vulgaris, treated with garlic in addition to anti-tubercular therapy are described. The patients, 2 males and 1 female, presented with asymptomatic nodules on the face. One individual also had a nodular eruption on the dorsum of the hand. These brownish nodules were enlarging gradually. No systemic symptoms were complained of and palpable lymph nodes’ were absent in all three cases. The nodules contained thick jelly like brownish material. All three patients had a positive Mantoux test, normal chest X-ray and a positive skin biopsy for granuloma. No bacilli were isolated. Antituberculous therapy with Rifampicin and INH was started alongwith two cloves of garlic minced in honey twice daily. Marked improvement was noted in the lesions with complete resolution in four weeks. Therapy was continued for six months. Lupus vulgaris is the commonest form of post-primary cutaneous tuberculosis. The lesions are mostly accral with peripheral extension and central atrophy. The tubercle bacilli after finding entry in the skin are engulfed by the cells of the blood and the tissues. They multiply here and this brings about a change in the tissue forming a new type of tissue which constitutes the tubercle. The destroyed cells break up and form the caseous material. The treatment comprises of a full course of antituberculous therapy. Garlic was used for its anti-infec­tive action on tuberculosis by Hippocrates. Its antibac­terialpropertywas then demonstrated by many workers all over the world. Garlic used in the presented cases, accelerated the cure rate and reduced scarring. The exact mode of action of garlic in Lupus Vulgaris and its effectiveness in other types of tuberculosis needs to be further evaluated.

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