Garima Shah

Abstract

Introduction: Adult onset Still’ disease (AOSD) is a rare inflammatory disease which involves multiple systems and is of unknown etiology first described in 1971.It has more prevalence among young females and few studies show the exacerbation of symptoms during pregnancy. Patients usually presents with high grade fever, arthritis, arthralgia, salmon pink rash, organomegaly, lymphadenopathy but rarely can present with pleural symptoms, cardiac symptoms. Several criteria’s are used for diagnosis but Yamaguchi’s has the highest sensitivity of 93.5%. Yamaguchi’s classification criteria includes major and minor criteria’s and exclusion criteria’s. Although diagnostic criteria are there but AOSD till date is a diagnosis of exclusion. All the causes of clinical symptoms should be excluded which involves malignancies, infections, inflammatory conditions, autoimmune diseases before the diagnosis of AOSD is made. Case Report: A 26-year-old female with G2P0010 and POG 6 weeks presented to medicine OPD with high grade fever associated with chills and rigors from 1 week. She was also complaining of stiffness and pain in multiple joints with chest pain, easy fatigability. She was having rashes on upper back below nape of neck. All the necessary investigations were carried out. It was found that she was also having right sided pleural effusion and severe microcytic hypochromic anemia. After batteries of investigations and consultation by obstetrician, rheumatologist, dermatologist diagnosis of Adult Onset Still’s disease was made. It was a diagnosis of exclusion. Patient was started on steroids and she responded well. All the symptoms including pleural effusion was subsided. Discussion: Adult onset still’s disease is a form of still’s disease. It is a rare systemic auto-inflammatory disease. Yamaguchi is the most sensitive criteria but till date it is diagnosed after excluding possible causes of malignancies, infections and autoimmune conditions. Sometimes patients do present with rare symptoms like pleural effusion, pericarditis some may present as acute respiratory distress syndrome or mild symptoms like cough, pleuritic chest pain. In our case also all the possible causes were excluded as patient presented with pleural effusion for the first time during pregnancy, so the impact of the disease on the fetal outcome was also considered. Conclusion: AOSD has always been a diagnosis of exclusion but as in our case and cases with similar presentation AOSD should be consider as a differential diagnosis. Although there are only few studies which show that there is fatal outcome of pregnancy in AOSD however there are studies showing exacerbation of symptoms of AOSD during pregnancy. Its early diagnosis and prompt treatment can be helpful in the better outcome of pregnancy as well as better prognosis of disease.   Keywords: Adult onset stills disease, Pregnancy, Pleural effusion.

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Introduction: Hypothyroidism is among the common clinical conditions which are encountered in the medicine OPD. An autoimmune disorder called Hashimoto’s thyroiditis is a common cause for hypothyroidism followed by over response to hyperthyroidism treatment, radiation therapy, medications, congenital disease etc. Patients can present with sensitivity to cold, weight gain, constipation, menstrual abnormalities, and slow mentation with irritability, dry skin, hair loss, and fatigue. Rarely, uncontrolled hypothyroidism can present as pericardial effusion, pleural effusion and ascites. Ascites as the feature of hypothyroidism is uncommon and only less than four percent of patients with hypothyroidism /develop ascites.As it is rarely presented as ascites so its diagnosis is delayed but once it is diagnosed, treatment leads to clinical improvement. Case Report: A 20-year-old female presented to medicine OPD with non- tender abdominal distension, vomiting. She was a known case of Hashimoto's thyroiditis an autoimmune disorder; however, she was not compliant to thyroid medication. All necessary investigations were carried out to rule out the cause for ascites. With all the negative reports including imaging and supportive fluid cytology we attributed the symptoms to uncontrolled hypothyroidism as the patient was non-compliant to the thyroid medications. Also the picture of macrocytic anaemia in our patient supported the diagnosis. She was started on levothyroxine and was counselled. On a follow-up visit there was dramatic improvement of all the symptoms including ascites and her TSH was normal-2.017. Discussion: Ascites as a symptom of hypothyroidism is rare and its pathophysiology is not fully understood however there are few theories and studies in the past which do explain ascites as the manifestation of hypothyroidism. Conclusions: Severe uncontrolled hypothyroidism though uncommon but can cause ascites. Being a reversible cause of ascites, it becomes important for clinicians to take hypothyroidism as one of the differential diagnosis for ascites. Our case supports the need of taking hypothyroidism as one of the cause, as it is easily treatable and patient can show dramatic improvement.   Keywords: Hashimoto's thyroiditis, Uncontrolled hypothyroidism, Ascites

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Introduction: Anemia is a major concern during pregnancy especially in rural areas where females are nutrient deficient. Apart from nutritional deficiency there are many causes of anemia like anemia of chronic diseases, thalassemia, neoplasia etc. Many studies in the past revealed a correlation between blood groups and hemoglobin levels. In this study we have tried to establish the correlation between blood groups and hemoglobin among pregnant females in rural population of Himachal Pradesh. Objective: To find out the correlation of hemoglobin level and blood groups during pregnancy. Materials and Methods: Blood groups and hemoglobin levels are investigated during antenatal checkup. We have taken data of 120 pregnant females visited to the OPD for routine antenatal checkups. Result: Among studied population A positive is the commonest blood group followed by B positive while anemia is most prevalent in B positive blood group. Conclusion: Anemia is a major concern among pregnant females as it effects the outcome of pregnancy. Many females have to go under caesarean section due to anemia related complications. So this study of correlation between blood groups and hemoglobin levels help to screen the pregnant females prone for anemia during first visit itself so that the treatment and the follow-up can be done as per the requirement of the patient.   Keywords : Blood groups, Hemoglobin levels, Pregnancy, Rural population.

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Introduction: Hydatid cyst is a parasitic infestation caused by Echinococcus granulosus. The spleen being rarely involved by the parasite, commonly involved organs are liver followed by lungs. It constitutes only 4% of abdominal hydatid diseases. Its worldwide incidence is 0.5 to 4%. In this case report, we present a case of young boy with concomitant splenic and liver hydatid cysts. Case Report: A 8-year-old boy, resident of Chamba district was presented with abdominal pain, fever and left upper quadrant swelling. The swelling had started enlarging over past 4 months. After necessary investigations it was diagnosed as hydatid cyst of spleen concomitant with liver and was confirmed by histopathological examination of the cyst membrane. All routine investigations other than anemia of 9.4 mg/dl and raised Ecchinococcus IGG serum levels, all other tests were within normal range. Discussion: Splenic hydatid is a rare entity and among abdominal presentations of hydatid diseases its incidence is very low, being 4% only. Diagnosis can be made on CECT abdomen along with the Echinococcus IGG serum levels, cytology of aspirated cystic fluid and then can be confirmed on histopathological examination of the cyst membrane sent for the histopathological examination. Conclusion: This case report emphasizes the need of considering hydatid cyst as a differential with uncommon presentation of the disease even in non- endemic area, as in this case patient presented with splenomegaly and abdominal pain.   Keywords: Hydatid cyst, Spleen, Non- endemic area

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