A 57-year-old man with diabetes and chronic hepatitis B presented with epistaxis and symptomatic anaemia. His past medical history was relevant for recurrent presentations with epistaxis resulting in chronic iron deficiency anaemia requiring transfusions. Physical examination reviewed multiple telangiectasias affecting the tongue, lips ( Figure 1A), face and scalp, digits and the palmer aspect of the hands ( Figure 1B). He also has numerous telangiectasias in the nasal passage. Patient recounted that bleeding can be severe; profuse epistaxis and bleeding from fingertips and scalp with spurting that can reach the ceiling. Upper gastrointestinal endoscopy showed several telangiectasias affecting the duodenum. Computed tomography scan showed multiple small arteriovenous malformations (AVMs) affecting the liver. Brain and chest scans were normal. Each episode of epistaxis was treated with nasal packing and cauterization. Embolization of the left internal maxillary artery had to be done ( Figure 1C) in a previous admission. There was no family history of similar condition.Osler-Weber-Rendu Syndrome (Hereditary Haemorrhagic Telangiectasia) named after Sir William Osler (Canadian physician), Frederick Parkes Weber (English dermatologist) and Henri Jules Louis Marie Rendu (French physician) who independently described the condition in the late 19th and early 20th centuries is a rare autosomal dominant condition (mutation endoglin [HHT1] or ACVRLK1 [HHT2] genes) characterized by presence of multiple AVMs and recurrent epistaxis. 1 Clinical diagnosis is based on the Curacao criteria: (i) spontaneous recurrent epistaxis, (ii) mucocutaneous telangiectasia, (iii) AVMs of visceral organs and (iv) first degree relatives with similar condition. The diagnosis is definite if 3 criteria and possible if only two criteria are met. The condition only becomes apparent in adulthood. Recurrent epistaxis and chronic iron deficiency anaemia are common presentations. Large AVMs can be associated with high-output cardiac failure due to shunting and stroke due to paradoxical embolization. 2 Treatment consists of iron replacement, transfusions and ablative therapies for the telangiectasia. 3 Thalidomide (anti-angiogenesis) can be tried but recently anti-vascular endothelial growth factor antibody (Bevacizumab) has been shown to be beneficial. 4Consent has been obtained from patient for publication. Figure 1. (A) Telangiectasias on the tongue, lip and peri-oral region, (B) palmer aspects of the hands and (C) post-embolization image showing contrast blush in the nasal, upper lip and hard palate areas.
The current study identifies the spatial distribution of COVID-19 cases and its association with meteorological and social variables in Punjab (densely populated province of Pakistan). To identify the COVID-19 propagation, the weekly growth, recovery, and deaths rate have also been calculated. The geographic information system (GIS) has used to determine COVID-19 impacts on gender (male/female), age groups, and causalities over an affected population (km −2 ) for the period of 11th March to 12th August, 2020 in each district of province. Our results show that 43 peak days (where daily positive cases were above 900) have been observed in Punjab during 27th May to 8th July, 2020. The high population density districts, i.e., Lahore and Islamabad, have been affected (five persons per square kilometers) due to COVID-19, whereas the maximum death tolls (> 50 persons per millions) have also been observed in these urban districts. The meteorological variables (temperature, humidity, heat index, and ultraviolet index) show negative significant relationship to basic reproduction number (R0), whereas daily COVID-19 cases are positively correlated to aerosols concentration at 95% confidence level. The government intervention (stringency index) shows a positive impact to reduce the COVID-19 cases over the province. Keeping in view the COVID-19 behavior and climatology of the region, it has been identified that the COVID-19 cases may likely to increase during the dry period (high concentration of aerosols) i.e., October–December, 2020 and post-spring season (April to June), 2021 in urban areas of Pakistan. This study provides an overview on districts vulnerability that would help the policy makers, health agencies to plan their activities to reduce the COVID-19 impacts.
Background: Histopathology is an important diagnostic modality for vesiculobullous lesions, however the diagnosis may at times require use of Immunofluorescence techniques which are expensive and not widely available. The aim of this study was to determine the histopathological spectrum of vesiculobullous diseases and to determine the role of clinic-pathological correlation in diagnosing bullous lesions. Methods: This was cross sectional validation study conducted in a tertiary care hospital, over a period of 18 months. All the clinically diagnosed cases of bullous diseases were included and examined as histological sections by three histopathologists. Results: Out of 58 total cases, the most frequently diagnosed lesions included Pemphigus vulgaris (27%), Bullous pemphigoid (13.8%) and Pemphigus foliaceous (12.1%). Females comprised 55% of cases, age distribution was wide but most patient were in age bracket of 20–39 years. Conclusion: There was 89.6% correlation between clinical and histopathological diagnosis. Only 2 cases were sent for Immunofluorescence studies, as histopathology was inconclusive in those cases. Therefore, we conclude that histopathological examination along with clinical correlation is a very useful way of diagnosing vesiculobullous disorders
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