Bacterial meningitis in a known case of steroid-resistant nephrotic syndrome

Nephrotic syndrome (NS) is a kidney disorder in which, excess protein is being excreted through urine. While most cases of idiopathic nephrotic syndrome respond to steroid therapy and experience a limited number of relapses prior to complete remission, some cases suffer from frequent relapses and become steroid-dependent or are primarily steroid-resistant. Treatment options are limited to immunosuppressive drugs with significant side effect profiles. Infections in nephrotic syndrome are common and can be severe. Meningitis is one of the complications associated with nephrotic syndrome. Here, we report a child with steroid-resistant nephrotic syndrome (SRNS) with meningitis. Early detection and appropriate treatment of these complications can be lifesaving.

Atypicals

“Major depression,” a non-existent disease, was the barrier to the development of new drugs for mood disorders, while “schizophrenia” was the stumbling block for the development of new drugs for disabling disorders of connectivity and mobilization. Psychopharmacology failed as a scientific paradigm when depression and schizophrenia became pipelines for billions of dollars in profit for the pharmaceutical industry. Also, antipsychotics like Smith Kline’s chlorpromazine, which marketed in the United States in 1954, caused movement disorders as a significant side effect. Finally, the real story of the atypicals shows how psychopharmacology was downgraded through the conversion of science into commerce. Clozapine, the first of the true atypical antipsychotics, turned out to be the most effective and the most dangerous.

Pseudohyperaldosteroism during itraconazole treatment: a hitherto neglected clinically significant side effect

We describe a married couple who both presented with hypertension and hypokalaemia. Both patients were diagnosed with pseudohyperaldosteronism triggered by the widely used antifungal drug itraconazole. This effect appears to be dose-dependent, where a daily intake of 100 mg itraconazole is enough to induce pseudohyperaldosteronism. Clinicians should be aware of pseudohyperaldosteronism as a possible adverse effect of itraconazole, and we recommend monitoring potassium levels and blood pressure in all patients receiving this drug over a longer period of time. Voriconazole is probably an alternative antifungal treatment to itraconazole but also with this drug potassium levels should be monitored.

When Your Pituitary Fails - A Rare Case of Pituitary Dysfunction Due to Nivolumab and Ipilimumab

Introduction: Immunomodulators like Nivolumab and Ipilimumab are important regimens in many malignancies. However, their use is linked with the rare side effect of pituitary dysfunction that if screened and treated can prevent misdiagnosis. Case Description: A 56-year-old male with a history of renal cell carcinoma status post bilateral partial nephrectomy with metastasis to the lung on Nivolumab/Ipilimumab presented with dizziness. He endorsed difficulty with balance, nausea, decreased appetite, feeling dehydrated and recent blood pressure readings in the 90s. Vitals on presentation were stable. An MRI, from 2 weeks ago, showed a slightly enlarged sella but no metastatic disease. The next day, he became hypotensive with minimal response to fluids and was started on Midodrine. However, considering his persistent hypotension, his cortisol level was checked and found to be profoundly low (<1). Literature review of his immunomodulator revealed the possibility of central adrenal insufficiency. In addition, he was noted to have a low TSH (0.02) with normal FT4 (1.08). Subsequently, his ACTH level was also found to be low (<1.5) which further elucidated a central cause for his adrenal insufficiency. Therefore, he was ultimately treated with PO hydrocortisone with plans to taper off in the next few weeks. Conclusion: This case demonstrates a rare yet significant side effect of Nivolumab/Ipilimumab therapy. Timely diagnosis and therapy can alleviate symptoms due to associated hormonal deficiencies. Moving forward it will be interesting to see if starting prophylactic steroids or routine screening will allow us to diagnose pituitary dysfunction due to Nivolumab/Ipilimumab earlier.

Use of topical nasal steroid spray in the treatment of non-specific chronic pharyngitis- our experience

Background: The present study was done to find the effectiveness of nasal steroid spray in the treatment of non-specific chronic pharyngitis.Methods: The present prospective study was carried out in department of Otorhinolaryngology and Head and Neck surgery, Government Medical College Jammu from July 2017 to March 2020. Patients were selected randomly from the ENT OPD, a detailed history was taken, thorough clinical examination was done to confirm the diagnosis and exclude all other existing illnesses and associated problems. Fluticasone nasal spray was used to see the relief of symptoms. Persistent relief was central to be considered proof of effectiveness of the treatment.Results: 40 patients were taken up for the present study, out of which only 32 patients showed relief in symptoms. 25 patients showed relief of symptoms with only 1-2 sprays. 8 patients did not report any relief of symptoms even after continues use of steroid nasal spray for 3-4 weeks. No significant side effect was noticed in any patient.Conclusions: In the present study, it is concluded that use of steroid (fluticasone) nasal spray in well selected cases of non-specific chronic pharyngitis is very effective, safe and cheap.

Comprehensive Rehabilitation of Acupuncture Combined with Sequential Therapy of DL-3 n-Butylphthalide for Subacute Stroke

The purpose of this trial was to examine the effect of acupuncture combined with 90 days’ NBP continuous habitual therapy and routine rehabilitation training could more effectively improve the physical movement, life activities, cognitive and psychological disorders of stroke patients. Our trial was a double-center trial and retrospective cohort study. The Acupuncture group received additional bedside acupuncture treatment and was given NBP injection 100ml twice a day in the first 14 days, and Sequential NBP soft capsule 200mg three times a day in the next 76 days. The No Acupuncture group only received conventional rehabilitation treatment. Primary outcomes were NIHSS, ADL and mRS which were evaluated in 6 months. Secondary outcomes included MMSE, MoCA, HAMA and HAMD; all were evaluated in 6 months. And the adverse reaction or other serious adverse events were evaluated at each time. We found that this therapy could significantly increase the scores of ADL, MMSE, MoCA, decreased the scores of NIHSS, mRS and the incidence of HAMA, HAMD of patients with ischemic stroke (P<0.05), which indicated that comprehensive rehabilitation of acupuncture as an additional therapy combined with the 90 days’ NBP sequential therapy could improve the cognitive, psychological and behavioral functions of ischemic stroke without significant side effect.

Prevalence of Gingival Hyperplasia Induced by Anticonvulsants: A Systematic Review

Objective: Gingival hyperplasia (GH) is one of the side effects of anticonvulsant drugs. The aim of this study was to verify the prevalence of GH associated with the use of anticonvulsant, through a systematic review. Material and Methods: Systematic search was done at databases Pubmed and Embase between January 1984 and March of 2020 for identification of articles addressing the prevalence of GH associated with the use of anticonvulsant drugs. The methodological index for non-randomized studies (MINORS) was independently assessed for quality in the selected papers. Results: The search identified 4.471 references. Nine articles were selected and evaluated 632 participants. All of the studies included in the systematic review showed a low risk of bias. The anticonvulsants used by patients were carbamazepine, ethosuximide, phenytoin, primidone, phenobarbital, sodium valproate. The studies showed a correlation between different types of anticonvulsants and GH prevalence, with a range from 0% to 73%. Among the anticonvulsants used, phenytoin showed the greatest incidence of GH, varying between 15.61% and 73% in patients. Conclusion: In the analysis of the results obtained in the literature, it is possible to notice that the great majority of studies presented incidence of GH associated with anticonvulsant use. However, further studies are necessary to understand the anticonvulsant action mechanism inducing GH, as well as the prevention forms, given that GH is a significant side effect. KEYWORDS Anticonvulsants; Gingival hyperplasia; Prevalence.

IgA nephropathy after pembrolizumab therapy for mesothelioma

The use of immune checkpoint inhibitors (CPIs), such as pembrolizumab, for the treatment of cancer, is now prevalent. CPIs are associated with a significant side effect profile, termed immune-related adverse events (irAEs). Renal irAEs, such as interstitial nephritis, are rare, and CPI-related glomerulonephritis even rarer. This is a case report of a 72-year-old man with mesothelioma of the left lung, whose serum creatinine rose during pembrolizumab treatment. Renal biopsy revealed IgA nephropathy. Withdrawal of therapy for 2 months saw no improvement in renal function, and following recommencement, serum creatinine fluctuated at approximately 1.4 times original baseline. This report will highlight the renal irAEs to be the aware of when starting CPIs, and the importance of early renal biopsy in management.