Health & Fitness

Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Fellow Nephrology in Aga Khan University Hospital, Karachi " Pakistan. For more Dissertation or seeking Dissertation help visit www.articlesbridge.com The Most popular website that offers information Research on different Disease and Case Studies. Please leave the links intact if you wish to reprint this article.

Case History

? Admitted via clinic on 25-06-2007 for
? Fever off and on-------- 8-9 months
? Abdominal Pain --------- 2-3 weeks

In Gilgit she was being treated as a case of genital Tuberculosis without any objective genitourinary complaints or symptoms
She took ATT for 2 months and then stopped b/c of drug induced Acute Hepatitis.

Fever
8-9 months off and on
High grade up to 103-104 F, no chills/rigors
No urinary or chest complaints but she had upper abd. Pain, moderate in intensity, no radiation, no vomiting but nausea was present with ass. Weight loss.

Clinical Examination:

§ Alert awake oriented, toxic look
§ Pulse Rate: 90 beats/minute regular
§ Blood Pressure: 160/80 mmHg
§ Resp. Rate: 20 b/minute
§ Temp: 36.8 centigrade
§ Pallor with Icteric
§ Malar Flush but no rash
§ B/L pitting pedal edema
Clinical Examination:

§ RHC tenderness, hepatomegaly 2 fingers below Rt costal margin, splenomegaly 1 finger, positive shifting dullness.

§ S1 and S2 audible, Panystolic murmur in mitral area radiating to axilla, no gallop.

§ Chest: B/L symmetrical shape and resp movements, equal chest expansion B/L, with NVB except at Rt basal region which had decrease air entry.

Clinical Examination:
? CNS: Alert, OrientedX3, no focal sensory or motor deficit, plantars normal.

? Musculoskeletal System: No positive findings
Labs:
11-06-2007
Hb: 10.2 gm/dl (NN)
Hct: 27.8
Wbc: 7.4
Neutrophils: 73.8%
Lymphocyte: 21.4%
Plat: 30
Retic=6.8
FBS: 110mg/dl
LDH: 8752

Labs

PTT=25.3/12 TB=5.9 Coombs ++
INR=2.12 DB=3.7 CRP = 8.3
APTT=68.7/30 IB=2.2
D-Dimer=0.87 GGT=81
MP -ve SGPT=53
MP ICT -ve ALP=348

Urine DR:
Dark yellow Protein +3, bil +3, Hb trace, rest normal

§ 24 hrs urinary protein was 7080 mg/24hrs

§ She was started on broad spectrum ABx, IV
hydration and supportive management initially

CXR
Rt. Lower lung consolidation with possible
consolidatory changes in the Lt lower lung field,
findings are suspicious for pneumonia.
she was already being treated for pneumonia.

US Abd:
Fatty infiltration of liver, sludge filled
Gallbladder, mild ascites.

Her CT Abd and Pelvis

with contrast was done considering
disseminated TB which showed mild B/L
pleural effusion with mild to moderate
ascites, no paraaortic lymphadenopathy

? Ascitic Fluid DR
Glu=70
prot=814
TLC=100
N=10
L=90
RBC +++

? During the hospital stay
? She became short of breath(14/06/2007)
? Her CXR showed Pulmonary edema

ABG
7.49/37.8/70.8/28.9/+5.9/95.3 on 6L Fio2

Trop I x2 were negative
She was treated with IV diuretics
Cardiology service was involved they
continued IV diuretics

Echo:
EF 60%, moderately dil. Lt Atrium
LVDD grade II
Mod-severe MR, mild TR
Mild PHTN, no vegetations/clots

Her Autoimmune profile was sent, and in the mean
while bone marrow was done to send TB CS and
cause for worsening Bicytopenia (dropping PLTs &
Hb) under cover of FFPs.

GI service was also involved for deranged LFTs
They suggested to send autoimmune workup
Which was already sent.

? 6-8 hrs after bone marrow Pt started having heavy bleeding from bone marrow procedure site and she was Tx with FFPs & platelets and with in next 12 hrs she started bleeding from every site (GI, oral cavity, Nose), Hematology was involved they suggested DIC workup Which was sent and which turned out to be negative
? Twice daily IV omeprazole was converted into infusion.

Bone marrow aspirate:
? hypocellular/dilute specimen
? Few erythroid and myeloid precursors.
? No megakaryocyte seen

Results of bone trephine (H&E) section:
? Erythroid hyperplasia with nuclear to cytoplasmic asynchrony.
? Few large cell seen ?early precursors. normal myeloid precursors.
? Adequate megakaryocytes. No metastatic infiltrate to granuloma seen.

Final Report:
§ Autoimmune hemolytic anemia ?cause.
§ megaloblastic features on bone trephine can be due to folate deficiency (secondary to hemolysis).

§ Pt was already kept on folic acid.

§ Her bleeding continued and ENT
service was involved for nasal packing

§ She was transfused with multiple
PRBC, FFPs, CryoPPT and was given factor VII (novoseven) on the advice of hematologist

? Multiple blood CS, Ascitic fluid CS, BM CS including AFB CS were sent which were negative.
? Her CCHF was sent which was also negative
? Her Ascitic fluid cytology was negative and so was autoimmune profile except AntiDsDNA which was 11.4 (n=0-6), Anti PLP & anticardiolipin Ab were negative
? C3=0.57 (n=0.88-2.01), C4=0.20 (n=0.16-0.47)
? She was started on pulse steroid
? After 3 days of bleeding and supportive transfusions she started dropping Spo2 on room air, able to maintain Spo2 at 96% on 15L Fio2 and her GCS dropped to 5/15, family was not agreed for intubation despite counseling.
? ABG=7.49/37.8/70.8/28.9/+5.9/95.3 on 15L Fio2
? She was maintaining blood pressures initially then she started having hypotension hence was started on inotropic support but on 25 June 2007 at 1430 hrs she had a sad demise.
Questions/Queries
? Whether she had SLE or something else?
? What was the cause of bleeding?
? Anything additional in the management of this patient which would have saved her life?
? What about her previous diagnosis of TB?
? If she would have been correctly diagnosed earlier would she able to survive?

SYSTEMIC LUPUS ERYTHROMETOSIS
(SLE)

DEFINITION

SLE is the prototype of a multisystem disease of autoimmune origin characterized clinically by acute/insidious onset chronic, remitting & relapsing in it?s course virtually affecting any organ of body & biochemically by presence of circulating autoantibodies against diversity of antigen.

EPIDEMIOLOGY

? 1:2500 in general population
? 1:700 in women
? 9:1 Female to male ratio
? 2:1 Female to male ratio in childhood & in age group above 65
? More common in African-American women.

Clinical Features
Constitutional Symptoms - Fatique, Fever
Arthralgia, Myalgia, Weight Loss

Cutaneous
Acute Skin Lesions - Generalized, Erythema, Bullous, Butterfly Rash
Subacute - Erythematous Palpable Plaques Associated With Ro/Ssa
Chronic Discoid
Alopecia
Raynaud

Clinical Features
1. Renal - Acute Renal Failure
Chronic Renal Failure
Nephrotic Syndrome
Nephritis
Pyelonephritis

Clinical Features?..
3. Pulmonary - Pneumonitis
Pleurisy
Pleural Effusion
Pulmonary Embolism
Pulmonary Fibrosis
Alveolar Hemorrhage

4. G.I.T. Dysphagia
- Mouth Ulcers
- Peritonitis
- Pancreatitis
- Mesenteric Vasculitis
- Bowel Infarction

Clinical Features..
5. Cardiac - Pericarditis
- Endocarditis (Libman-Sachs)
- Myocarditis
- Coronary Artery Disease

6. Reticulo-Endothelial
- Lymphadenopathy
- Splenomegaly

Diagnostic Criteria

Diagnosis - Acr Criteria
1. Malar Rash
2. Discoid Rash
3. Skin Photosensitivity
4. Painless Oral Or Nasopharnygeal Ulcers
5. Non Erosive Arthritis Or Arthralgia
6. Serositis (Pleurisy, Pericarditis)
7. Renal Involvement
8. Neurologic Disorders
9. Haematologic Disorders
10.Immunologic Disorder (Le Cells, Anti-Dna, Anti-Smith, False + Ve Vdrl, Aca
11. Ana

Any Four Out Of The Above Criteria

Labs
Laboratory
1. Leucopenia < 4,000
2. Thrombocytopenia
3. Anaemia - Hemolytic, Normochromic, Normocytic
4. Markedly Elevated Esr > 100
5. Usually Normal Crp
6. Ana - Present In 95% Homogeneous, Speckled
7. Anti Ds-Dna -Specific But Not Sensitive Suggest Severe Or Lupus Nephritis
8. Anti- Sm-Specific
9. Anti Ro/Ssa, La/Ssb - Neonatal Lupus, Congenital Heart Block
10.Anti Ribosomal P-Lupus Cerebritis
Labs..
11. Anti-Phospholipid (Igg Or Igm) - Aps
12. False Positive Vdrl

Lupus Nephritis
1. Albuminuria > 0.5g/24 Hrs Or Dipstick 3+
2. Casts (Rbc, Granular, Tubular, Mixed)
3. Haematuria (> 5rbc/Hpf)
4. Elevated Creatinine

Treatment

Simple Analgesics
Nsaids
Steroids
Hydroxychloroquine

Dmards - Methotrexate, Azathioprine,
- Cyclosporin, Cyclophosphamide,
- Mycophenolate Mofetil

Complications
- Opportunistic Infection
- Avascular Necrosis
- Premature Atherosclerosis - Myocardial Infarction
- RECURRENT ABORTION
- NEONATAL LUPUS

Prognosis
? Overall five years survival is more than 90 %

? Early mortality is due to organ failure or sepsis

? Late mortality is due to CVS complications

For more information visit: Hoodia Balance and Weight Los Products

Hoodia Gordonii is a very interesting ?ancient plant" that has been used for thousands of years but just beginning to catch on to the ?Western world Hoodia" for weight-loss. The huge media coverage has led to a flourishing industry in Hoodia Gordonii based products, whether they be ?Pure Hoodia" or Hoodia as just one of the ingredients of an already existing weight loss product.

But before you rush off to buy a Hoodia supplement you should understand a bit about what studies have shown so far with respect to Hoodia Gordonii for weight loss. Knowing these facts will help you navigate through Hoodia product and buy the best product to avoid the fake ones.

Know The Facts About Hoodia:i) There are a variety of Hoodia plants. Only the Hoodia Gordonii class contains an active element that helps suppress your appetite. As the demand for Hoodia Gordonii is far surpassing the supply, some Hoodia sellers are using unreliable but advertising their products as Pure Hoodia even though it might have been made from a different Hoodia plant than the Hoodia Gordonii.

ii) Of course many companies claim their Hoodia extract can slim you down, the only thing that has been proven so far is the ?P57 molecule". ?P57" is the ?active ingredient" in Hoodia Gordonii that was isolated. It was licensed to a company named ?Phytopharm" that conducted a study using it. It was found that morbidly obese people using ?P57" ate on average of 1k less calories per day. Obviously this is the reason why so many people think Hoodia for weight-loss is the new rescuer for the obese and people looking to slim down.

iii) What is most important to keep in mind is that as long as the Hoodia products are extracted from real Hoodia Gordonii, it should also contain some of the active ingredient in it. Study shows that only the core of the plant has the active ingredient.

So can Hoodia slim you down? And the answer is a big Yes! But only if you buy a real product and avoid the false ones.

For more information visit: Hoodia Balance and Ismaili Portal

The Hoodia Gordonii diet pill is the newest catch phrase in the weight-loss industry today. Everyone seems to be sticky with this secret, but still quite a few are susceptible about this miraculous plant. How can it help you lose weight? How does it work? And why it was not been heard before? Well, some of it appears to be true, but you will appreciate that everything needs some time to establish its truth. Gordonii product has also taken its own time impress on the weight-loss process.

Hoodia Gordonii diet pill has originally been in South Africa for quite some time, but was only recently exposed to be an appetite suppressant. Many reports, including some from well-known media, revealed that Hoodia could make you feel full faster and stay full longer because of its obvious ability to suspend your hunger. The "Bushmen", one of the oldest tribes of the Kalahari deserts have been eating Hoodia Stems from their ancestral time and have been familiar with its "thirst and hunger" quenching capabilities. That is why, when using Hoodia Gordoni it is important to have sufficient ?hydration" on top of a healthy diet. Even though Hoodia Extract is natural and able to work on its own to help safely restrain your hunger, it is essential that you incorporate it into a healthy lifestyle.

As with any weight loss product, your doctor should know what you are taking and how you plan to use Hoodia Gordoni in your life. Even though Gordonii Supplement is being depicted as the latest weight-loss wonder, do not let the propaganda get to you. Be realistic! And test the product to verify it"s creditworthy.

If you have a sweet tooth, or you find difficult to cut short diet, you should consider an appetite suppressant like Hoodia Gordonii at least for the first few months to lose weight. Depending on how much you are overweight now, most doctors" advice losing no more than four pounds a month. You should be able to do that easily.

for more information visit: Hoodia Balance and http://www.web2host.biz/SubmitArticle

The South African Hoodia Gordonii Cactus is known by many names. It is called xshoba or xhooba by the San Bushmen who have used it to treat indigestion, minor skin infections and as an appetite and thirst suppressant during long hunts. The scientific name is Hoodia Gordonii. It is actually a succulent so the names Hoodia cactus and South African desert cactus are actually misnomers, but they are commonly used. The plant resembles a cactus when seen growing wild in the Kalahari Desert.

There are problems associated with growing the South African Hoodia cactus for commercial purposes. First, logically, is temperature. In order to thrive the Hoodia cactus requires desert like temperatures. Second is time. It takes four or five years for the African Hoodia Gordonii cactus to reach full maturity. Quantities of the wild plant are extremely limited and are protected by the governments of South Africa from harvesting. Phytopharm, the first company to research the properties of the African hoodia cactus, has established plantations in South Africa, but will not begin to sell their patented product for at least a couple of years.

It is important to note that there are more than twenty different varieties of hoodia, but only Hoodia Gordonii is believed to contain the natural appetite suppressant. Some companies may be selling products that are purported to contain the African hoodia cactus, but if it is not Hoodia Gordonii, then it may not work. As with all health supplements, it is best to buy hoodia products from a reputable company that sells a complete line of products. In addition, dieters are advised to remember to drink plenty of water since hoodia suppresses thirst, as well as appetite.

By any name, the African hoodia cactus is a beautiful plant. Flowers are pale purple and appear after the plant reaches maturity. Even though dieters would love to have a large immediate supply, it is important to protect the wild African hoodia cactus from over-harvesting, so that it can be enjoyed by future generations.