Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) and acute generalized exanthematous pustulosis (AGEP) are two separate pathological entities of severe cutaneous adverse reactions (SCARs) with different etiologies and treatment strategies. Diagnosis is, however, complicated by the similarity in their clinical presentation. Although there are few claims of AGEP-SJS/TEN overlap, a simultaneous true overlap of SJS/TEN and AGEP has rarely been described in the literature.Here, we report a case study of a 61-year-old female with a known allergy to sulfa drugs presenting with altered mental status, generalized weakness, and erythematous and excoriated purulent wounds. Based on initial workup and extensive consultation, the patient was diagnosed with severe sepsis secondary to diffuse purulent cellulitis, community-acquired pneumonia, and acute renal failure due to prerenal azotemia from dehydration. She was treated with several antibiotics, starting with vancomycin, piperacillin/tazobactam. Six days later, antibiotics were de-escalated to ceftriaxone and metronidazole because of the patient's improved status. The medications were withheld when the patient started developing extensive blistering on day 8. Blood cultures ruled out any bacterial etiology. Skin biopsy confirmed overlapping features of AGEP and SJS/TEN. Due to the uncontrolled progression of her rash, she was transferred to the burn unit of a higher care center. This is potentially the first histologically confirmed case of AGEP-SJS/TEN overlap in the United States. In this case study, a conclusive diagnosis would have never been made without a biopsy, especially because the condition presented clinically as SJS/TEN. We, therefore, recommend considering a potential overlap of multiple pathologies at each presentation or suspicion of a SCAR and performing an early skin biopsy in order to provide definitive diagnosis and treatment.

Granulomatosis with polyangiitis (GPA, Wegener’s granulomatosis) presenting as rapidly progressive glomerulonephritis is not uncommon. The recognition of multisystem disease involving joints, kidney, and lung is critical for diagnosing Wegener's vasculitis. Here, we report a case study of a 52-year-old Bangladeshi man presented with a history of progressively worsening fever, recurrent cough, and hemoptysis. He developed renal failure within a month which was successfully treated with high-dose steroids, cyclophosphamide, and trimethoprim-sulfamethoxazole (TMP-SMX). Rapidly progressive glomerulonephritis can be a fulminant manifestation of GPA, in which case an immediate and aggressive treatment with pulse steroids, high-dose cyclophosphamide and TMP-SMX can be lifesaving.

Among several inflammatory bowel diseases, Crohn’s disease is associated with inflammation that may take place in any region of the gastrointestinal tract. The inflammatory process is most commonly associated with the ileum, often spreading deep into the bowel tissues, extending into multiple forms, such as strictures and penetrations. Currently, Crohn’s disease has no known cure. Various medical and surgical procedures are used to manage the condition. The underlying mechanisms of the disease are yet to be identified, with recent studies suggesting the influence of genetics, environmental factors, and the possible activity of pathogens. Newer studies also offer strong evidence that suggests a relationship between Crohn’s disease and the nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene, also known as inflammatory bowel disease protein 1 (IBD1) or caspase recruitment domain-containing protein 15 (CARD15). NOD2 is responsible for the mechanism in which the immune system identifies foreign microorganisms through the sensing of pathogen-associated molecular patterns in microorganisms. NOD2 can detect intracellular muramyl dipeptide (MDP) in the bacterial wall, thereby causing an inflammatory response. Three major mutations associated with the NOD2 gene are known to have an influence on Crohn’s disease (SNP8, SNP12, and SNP13). This article will discuss a number of studies to identify whether there is a relationship between Crohn’s disease and the NOD2 gene.

Obstructive sleep apnea (OSA) is a common, chronic, sleep-related breathing disorder characterized by repetitive episodes of partial and complete airway obstructions during sleep with repetitive apneas and hypopneas as a result. Common symptoms of OSA include snoring, nocturnal choking or gasping, excessive daytime sleepiness, nonrefreshing sleep, fatigue, nocturia, morning headache, and cognitive impairment. Snoring has the most sensitivity(82.6%) while nocturnal choking or gasping is the most specific (84%) Undiagnosed and untreated OSA attributed to hypertension (30%-70% of OSA patients), heart failure (140% rise in risk), CAD (30% rise in the risk of blockage), and stroke (60% rise in risk). Other long-term health consequences include diabetes, memory loss (including Alzheimer’s), depression, and other psychiatric conditions. Depending on the broad or stringent definition of OSA based on the apnea-hypopnea index (AHI), the prevalence of the condition in North America can range from 20-30% or 15% in males, and 10-15% or 5% in females. Asians and Indians have been found to have similar OSA severity, despite lower rates of obesity. However, research conducted among South Asians in the UK shows a higher prevalence of OSA than white Europeans. Limited research is done on OSA among South Asians in the US, particularly in the Bangladeshi community. The proportion of the population showing a high risk for the disease noticeably increases from 46 years onward. Male gender was found to be the major risk factor determining whether the subjects are at high, intermediate, or low risk. This conforms with other studies done previously. Although the study shows 30% of the population posing an increased risk for OSA, the outcome may be the same, lower, or higher after polysomnography. The author recommends a broader study with a follow-up of the intermediate and high-risk groups with an appropriate sleep study. Based on the preliminary findings, questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. Steps should be taken to increase awareness at the community level to improve compliance with annual physicals and reduce risk behaviors.

Background: Depression is not uncommon among medical students all over the world. Few studies have been conducted so far in Bangladesh to depict its actual prevalence and severity. So, the aim of this study was to assess the severity of depression and the level of difficulty faced by medical students in different academic years.Methods: This cross-sectional study was conducted in North East medical college of Bangladesh from January 2018 to June 2018 involving 443 students from 1st year to 5th year. Students were instructed to fill up the patient health questionnaire (PHQ-9) which incorporates diagnostic and statistical manual of mental disorders (DSM-IV) depression diagnostic criteria categorized as no, mild, moderate, moderately severe, and severe depression and also evaluates their level of function.Results: The prevalence of depression was quite high (79.68%). 196 (44.24%) and 157 (35.44%) students had mild and major depression respectively, while 90 (20.32%) showed no depression. Students with major depression were scored as moderate depression 24.38%, moderately severe depression 8.35%, and severe depression 2.71%. Moderate depression was significantly higher in year 1 and year 2 students in comparison to year 3, 4 and 5. Students from year 1 to year 5 with mild, moderate, moderately severe and severe depression experienced varying degree of difficulty in their daily activities. Almost all the students in all years with severe depression found themselves very difficult or extremely difficult to cope.Conclusions: High prevalence of depression among medical students is really alarming and underlying factors need to be addressed.

Antithyroid medications can cause antineutrophil cytoplasmic antibody (ANCA) vasculitis. However, no literature in English describes the coexistence of granulomatosis with polyangiitis (GPA) and untreated Graves' disease. We present a 19-year-old female with thyroid storm and additional complaints of cough, hemoptysis, nasal discharges, polyarthralgia, and skin lesions. Imaging showed peri-hilar cavities and acute-on-chronic sinusitis. Elevated cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA) and anti-proteinase-3 antibody levels plus histopathology of the nasal and skin biopsies suggested GPA. Propranolol, methimazole, and potassium-iodide resolved the thyroid storm. Induction therapy (steroids, rituximab) for GPA provided relief of chronic symptoms stressing the importance of early recognition and swift initiation of treatment Categories: Endocrinology/Diabetes/Metabolism, Allergy/Immunology, Rheumatology

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