Intravenous immunoglobulin (IVIG) is used in the treatment of a variety of autoimmune neurological disorders and is generally regarded as safe. We present a case series where IVIG causes transaminitis. The adverse effects are mostly due to the stabilizing agent used to prepare the IVIG (e.g., maltose in this series). While the adverse effects are usually self-limiting, physicians should be cautious in administering an IVIG preparation to these patients.
Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India. Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases. Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.
Aluminum phosphide is a common suicidal agent in an agrarian country like India. Toxicity is mostly due to the liberation of phosphine gas, which non-competitively inhibits cytochrome oxidase in the mitochondria causing cell hypoxia. It can involve almost any organ in the body, but the most common is cardiovascular system. Various cardiovascular manifestations are hypotension, myocarditis, pericarditis, congestive heart failure, various ECG changes like myocardial infarction, conduction abnormalities, various arrhythmias, and very rarely unmasking of the Brugada pattern. Here we are presenting a case in which the patient developed unmasking of the Brugada pattern in ECG, and gradually he improved symptomatically and ECG wise with conservative treatment. As unmasking of the Brugada pattern in ECG can lead to life-threatening arrhythmias, one has to be cautious and keep this in mind while dealing with a case of aluminum phosphide poisoning.
Multicentric reticulohistiocytosis (MRH) is a rare multisystem macrophage disorder of unknown etiology characterized by papulonodular skin and mucosal lesions, rapidly progressive erosive symmetric polyarthritis, and inflammation of internal organs. Most often, it is misdiagnosed as rheumatoid arthritis (RA). Here, we report the case of a 60-year-old woman found to have features of both MRH and RA with positive rheumatoid factor and high titer of anti-cyclic citrullinated peptide antibody in serum. It was confirmed by a histopathology of skin lesions, which showed diffuse histiocytic infiltrate with multinucleated giant cells. She was treated with methotrexate, hydroxychloroquine, corticosteroids, and nonsteroidal anti-inflammatory drugs and bisphosphonate.
Background: Hyperkalaemia in oleander (Nerium oleander) poisoning has been associated with a poor prognosis. Different electrocardiographic (ECG) presentations are possible because of vagotonia and hyperkalaemia. Methods/Results: We report a series of three cases of oleander poisoning in which ECG showed unusual hyperkalaemia features, such as bradyarrhythmia, sinoatrial block, atrioventricular block and junctional rhythm. Conclusions: If arterial blood gas analysis or laboratory values indicate hyperkalaemia in oleander poisoning, the hyperkalaemia should be treated immediately, even if the ECG does not show typical hyperkalaemia features.
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