Present Case Report Research Articles

Management of Ardita (Bell’s palsy) through Ayurvedic Approach

Bell’s palsy is the most common form of unilateral isolated lower motor neuron type of facial palsy. This is an idiopathic condition with abrupt onset leading to weakness of one-half of the face. The present case report is on the effectiveness of Nasya Karma and Shirodhara procedures in Bell’s palsy. A 35-year-old female patient visited the OPD with complaints of deviation of the mouth, improper closure of eyes, and dribbling of saliva for four days. She was diagnosed with Bell’s palsy. Bell’s palsy can be correlated with Ardita based on clinical features. The patient was hospitalized and managed with Sthanik Snehana (localized oleation /massage therapy), Sthanik Swedana (localized steam), Nasya Karma (medicine administered through nasal route), and Shirodhara (medicated decoction/oil pouring over the forehead) along with oral Ayurvedic formulations. She got noteworthy relief in all features in two weeks. The collected data emphasize the potential of Ayurvedic interventions in Bell’s palsy (Ardita).

Ayurveda Management on Palmoplantar Psoriasis- A Case Study

Psoriasis is an immune-mediated disease and a chronic proliferative inflammatory skin ailment. Probably it is associated with a genetic predisposition that can be triggered by stress. It can have negative impact on the physical, emotional and psychological wellbeing. Around 5% of all the psoriasis sufferers have palmoplantar psoriasis. It has a strong genetic component but environmental factors such as infections can also play an important role in the presentation of the disease. Palmoplantar psoriasis typically affects the skin of the palms and soles. Its morphologies are hyperkeratotic, pustular, or mixed. This disorder result in a substantial functional impairment and are chronic in nature. As a result, they are linked to a significant decline in life quality. Kushta roga is Vaivarnya and Dushti of twacha. Vipadika is included under Kshudra Kushta, characterized by Sputana in soles and palms with Vedana. Kushta is a disease of Bahudosha, Bhurodosha, the line of treatment to be adopted is Antah Parimarjana and Bahir Parimarjana chikitsa. This present study is on one such similar case of a male patient with thick skin lesion over both palms and soles with itching sensation, scaling of lesions & hyperpigmentation suffering over a period of 4 years. The treatment plan was based on the Samprapti of Vipadika Kushta. Assessment were done based on DLQI and PASI score. Nitya Virechana along with Shamana Chikitsa were selected as the line of treatment. Within few months of the treatment, the psoriatic lesions and associated signs and symptoms were healing effectively, subjective improvement in the quality of life. No adverse events were reported during the course of therapy and no recurrence was noticed as of reporting the present case report.

Bradycardic Arrest in a Child with Complex Congenital Heart Disease Due to Sugammadex Administration.

The neuromuscular blocking drugs rocuronium and vecuronium are often used during general anesthesia. These drugs temporarily paralyze the patient and thus both facilitate placement of an endotracheal tube and prevent any patient movement during surgery. Reversal of neuromuscular blockade is necessary at the end of surgery to avoid postoperative weakness and adverse respiratory events in the recovery room. Neostigmine, the traditional reversal agent, may not completely restore muscle strength. Sugammadex is a reversal agent that is more effective and quicker acting than neostigmine. In adults, sugammadex administration has rarely been associated with bradycardia and cardiac arrest. In healthy children, the bradycardia that occurs after sugammadex administration is benign and does not require intervention. There is 1 case report of a 10- to 15-second bradycardic arrest after sugammadex administration to a 10-year-old child with heart disease. The present case report describes an 8-month-old child with complex congenital heart disease who experienced a 10-minute bradycardic arrest after the administration of sugammadex. Pediatric anesthesiologists should be aware that sugammadex administration to children with heart disease may cause hemodynamically significant bradycardia.

Nephrotic Syndrome in Pregnancy - Case Reports

Nephrotic syndrome is a spectrum of kidney disorders with clinically significant proteinuria, peripheral oedema, hypertension, hypoalbuminemia, hyperlipidaemia, and hypercoagulable state. Pregnancy complicated with nephrotic syndrome poses significant challenges leading to maternal and foetal morbidity even in the absence of significant renal impairment. It leads to preeclampsia, foetal growth restriction, preterm birth and higher incidence of operative deliveries. Multidisciplinary approach involving high risk pregnancy team, nephrologist and neonatal care can improve neonatal and maternal outcomes. Here are the case reports of nephrotic syndrome managed with multidisciplinary approach with successful outcomes.
 Proteinuria in pregnancy is common ranging from mild increase to significant proteinuria. If there is significant increase it does not always necessarily be preeclampsia, it could be an underlying renal disorder. It is characterized by proteinuria in excess of over 3.5 g/day, peripheral oedema, hyperlipidaemia, hypoalbuminemia. Renal biopsy may reveal microscopic abnormalities. Prompt diagnosis, and multidisciplinary management can lead to successful outcomes. Here we are presenting case reports on pregnancies complicated with gross proteinuria which were managed with multidisciplinary inputs with positive outcomes.

Primary Hepatic Tuberculosis: An Unexpected Diagnosis

Background: Primary hepatic tuberculosis (PHT) is a rare form of extrapulmonary tuberculosis that affects the liver and is difficult to diagnose. The present case report describes a patient who was diagnosed with PHT and was successfully treated with a combination of anti-tuberculosis drugs. A 55-year-old diabetic male presented with a history of abdominal pain, fever and weight loss. An abdominal ultrasound and computed tomography (CT) scan revealed multiple hepatic lesions, and fine needle aspiration cytology confirmed the diagnosis of PHT. The patient was treated with a standard regimen of isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampin for another four months. The patient showed improvement in symptoms and the disappearance of hepatic lesions, as seen on follow-up ultrasound scans. This case highlights the importance of considering PHT in the differential diagnosis of patients with hepatic lesions, particularly in regions with a high burden of tuberculosis. Early diagnosis and prompt treatment can lead to a good outcome in PHT. J Com Med Col Teachers Asso Jan 2023; 27(1): 38-41

Simplified ELASTA-CLIP Before Transapical Mitral Valve Replacement

Residual and recurrent mitral regurgitation after transcatheter edge-to-edge repair are therapeutically challenging. In the present case report, we describe a simplified, transapical electrosurgical laceration and stabilization of clip procedure that represents an alternative and direct approach for electrosurgical laceration of mitral valve leaflets enabling transcatheter mitral valve replacement for recurrent mitral regurgitation after mitral valve transcatheter edge-to-edge repair.

Perioperative management of a morbidly obese patient with multiple myeloma for spine surgery—when the problem doubles up!

BackgroundMultiple myeloma (MM) patients are prone to pathological fractures due to osteolytic bone lesions. With improved perioperative care, outcome of patients with vertebral compression fractures presenting for surgical interventions has become better. However, perioperative care of such patients is challenging for the anesthesiologist.Case presentationHerein, we report the successful perioperative management of a 55-year-old multiple myeloma patient with the compression fracture of lumbar vertebrae 2nd to 5th, for which balloon kyphoplasty was planned in prone position.ConclusionsMultiple myeloma patients are at high risk of developing postoperative complications like acute kidney injury (AKI), pneumonia, and infections. In the present case report, we discuss and provide recommendations for better perioperative care to prevent perioperative complications.

Reccurent apthous with psychological stress predisposing factor – a case report

Background: Aphthous stomatitis (RAS) is a painful recurrent inflammatory process of the oral mucosa. Clinical features of inflammation in aphthous stomatitis in the form of ulcers on the oral mucosa can be single or multiple and have no relationship with a systemic disease. The etiopathogenesis of aphthous stomatitis is several predisposing factors in the manifestation of the oral cavity. This article presents case reports on RAS patients with stress-predisposing factors. 
 Case: In October 2019, A 52-year-old female patient came to RSIGM complaining of canker sores in several places in her oral cavity, namely on the right inner lip, left inner lip, floor of the mouth, and under the tongue. The patient has felt this condition for the last 2 years, but the canker sores have disappeared and reappeared. The Miller and Smith test showed that the score is 42. We diagnosed the RAS patients with stress-predisposing factors. 
 Case Management: The patient was given oral methylprednisolone and becomzed tablet and counseling management stress. 
 Conclusion: cases of recurrent aphthous stomatitis are caused by psychological stress which can cause recurrent ulcers in the oral cavity. Eliminating stress-causing variables is one of the key therapies for these diseases. some patients need counseling with experts in stress management in addition to systemic treatment according to the symptoms felt by the patient

Bilateral absence of musculocutaneous nerve in a cadaveric specimen

Knowledge of the normal course and distribution of the nerves of the brachial plexus in the axilla and arm, and of its possible variations, is essential for the proper management of upper limb nerve injuries, which is a relatively common occurrence in the clinical setup. Bilateral absence of the musculocutaneous nerve was observed during routine dissection of a female cadaver. The muscles of the flexor compartment of the arm were supplied by the median nerve bilaterally.The present case report should elucidate this variation and should aid in applying this knowledge in the clinical setup.

Bilateral Cerebral Venous Thrombosis with a Rare Presentation in a COVID-19 Patient: A Case Report

AbstractSince the COVID-19 pandemic started, millions of peoples are involved. The presentation of the disease varies from mild respiratory symptoms and multiple organ failure to coma and death. Neurological symptoms such as headache or seizure are also coincident with COVID-19. Thromboembolic events increase in COVID-19 patients due to hypercoagulability and inflammation, particularly in severely ill patients. Thrombosis may cause venous thrombosis, pulmonary embolism, or cerebral sinus venous thrombosis (CSVT). Cerebral sinus venous thrombosis is a rare phenomenon that is usually found in critically ill patients with bad prognoses. In the present case report, we present a 40-year-old man with COVID-19 confirmed by real-time polymerase chain reaction (RT-PCR) who was admitted due to acute bilateral visual loss due to bilateral transverse sinus thrombosis. Pseudotumor cerebri disease was confirmed through high lumbar puncture. Early surgical intervention (optic nerve fenestration) was performed and, fortunately, his visual acuity improved. Cerebral sinus venous thrombosis is a rare incident in COVID-19 patients, but due to irreversible complications, an early diagnosis is fundamental. In any neurologic change in COVID-19 patients, CSVT must be considered. Also, prophylactic thrombolytic therapy should be kept in mind as the patient is admitted.

Idiopathic External Cervical Resorption of the Impacted Second Premolar: A Case Report

The tooth impaction of the lower second premolars is an occasional condition but is still seen in clinical practice with a prevalence of 0.6–2.6%. The present case report describes a rare condition of the lower second premolar impaction. An 11-year-old female patient presented with the anteroposterior dental discrepancy, midline shift, and occlusal cant. Intraoral examination revealed the absence of the lower right second premolar with no space available for the eruption. X-ray examination revealed the impaction of tooth #45 in a vertical position, tilting of the adjacent teeth, and two-thirds root length development. The orthodontic treatment plan included space opening using a fixed appliance with a coil spring. The natural eruption of the tooth was expected according to dental age and root development. When the space was opened, no change in the position of tooth #45 was observed. Surgical exposure and active traction were performed. However, the intrusion and tilting of adjacent teeth were observed during the next appointments with no vertical change of tooth #45. Ankylosis was suspected as no tooth movement was recorded. The surgical luxation and osteotomy of the coronal alveolar bone of the impacted tooth were planned for the imminent forced eruption, which was expected due to the young age of the patient. Consequently, the crown of tooth #45 emerged and the bracket was placed. Further traction was planned to use a micro-screw. Following the traction, no vertical displacement of the tooth was observed in the subsequent appointments. Radiographic examination revealed radiolucency in the coronal third of the root. The patient was referred to the endodontist, and CBCT revealed external cervical root resorption in the late reparative stage. ECR in an impacted tooth, mimicking the manifestation of tooth ankylosis, can cause orthodontic treatment failure.

MANAGEMENT OF EKA KUSHTA WITH SHODHANA AND SHAMANA – A CASE STUDY

In Ayurveda, all skin diseases are explained under the disease Kushta. The word Kushta is derived from the sutra – “ Krishnati sarvam Vapuhu iti Kushtam” which means, the one which causes vikruta to Shareera is called Kushta. Kushta is broadly bifurcated into Maha kushta & Kshudra kushta. Eka Kushta is one among Kshudra kushta; those which do not affect the Gambheera dhatu. In the present case report, a 58-year-old male patient presents with pinkish red scaly appearance with silvery margins in both the upper limbs, lower limbs, abdomen, trunk and chest region associated with severe itching since 26 years. The patient was treated with Shodhana like Virechana along with Shamana aushadhis & reported with significant improvement in the condition.

The First Ever Robotic-Assisted Laparoscopic Radical Nephrectomy with Inferior Vena Cava Thrombectomy Performed in Thailand: A Case Report of Atypical Presentation of Urothelial Carcinoma with Tumor Thrombus

Background: Robotic-assisted surgery was proposed as an alternative to open surgery for management of inferior vena cava (IVC) thrombus together with radical nephrectomy in complex renal mass. Here, the authors reported the first case of this type to be managed via this surgical technique in Thailand. Case Report: A 76-year-old Thai female presented with right renal mass with tumor thrombus in the IVC extending 3 cm above the level of the renal vein. The presumed diagnosis was renal cell carcinoma of the right kidney with level 2 tumor thrombus in IVC, clinical staging T3bN0M0. The patient underwent robotic-assisted laparoscopic IVC thrombectomy together with right radical nephrectomy at Siriraj Hospital (Bangkok, Thailand) in May 2020. Results: The operation proceeded uneventfully without immediate complication. The postoperative reduction of IVC diameter was approximately 30%. Total IVC clamp time was 50 minutes, operative time was five hours, with docking time of 20 minutes and console time of 250 minutes, estimated intraoperative blood loss was 2,600 mL, and length of hospital stay was four days. At 30-days and 90-days postoperation, no thromboembolic event or compromising lower extremity venous return was detected. The pathological report revealed high-grade urothelial cell carcinoma with invasion into perinephric fat. Carcinoma involvement was observed in the tumor thrombus and IVC wall (T4N0M0). Conclusion: Robotic-assisted surgery of the IVC is a complex operation that requires robotic surgical proficiency and a highly experienced team. The observed success in the present case demonstrated the feasibly of this procedure in Thailand. Additional benefits include less postoperative pain, reduced blood loss, smaller surgical wound size, and shorter length of hospital stay. Keywords: Robotic-assisted laparoscopic radical nephrectomy; Inferior vena cava thrombectomy; Thailand

A RARE ANATOMICAL VARIATION OF BILATERAL BICIPITAL ORIGIN OF PLANTARIS MUSCLE: A CASE REPORT

The posterior calf group, plantaris muscle has a small fusiform muscle belly and a long slender tendon sandwiched between the soleus and gastrocnemius muscles. The case was reported during routine dissection at National institute of Ayurveda Deemed university, Jaipur. The subject was 31year-old male cadaver of north Indian origin. The Bilateral Bicipital origin of Plantaris Muscle was observed during the cadaveric dissection of the popliteal region. Two distinct PMS (Plantaris Muscles) were present, the SPM (superior Plantaris Muscle) and IPM (Inferior Plantaris Muscle). While the SPM originates from the lower lateral supracondylar ridge and the knee capsule, the IPM originates from the femoral condyle and SPM tendon splitting in to one part at the distal belly. The lateral side of the IPM tendon travels between GM (Gastrocnemius Muscle) and SM (Soleus Muscle) and ends at the calcaneal tendon. SPM and the medial side of the IPM tendon run along with the IPM tendon and insert at the fascia at the inner surface of proximal 1/3of the medial head of GM. The present case report introduces a new variation of the PM that should be taken into consideration.

Custom made cast post and core on a mandibular premolar using direct approach

Custom-made cast post and core plays a crucial role in the restoration of extensively decayed teeth, offering a level of flexibility that addresses the specific needs of each case. The core serves as an anchor within the root canal, providing stability and support for the subsequent prosthetic restoration. The process of creating a design for a cast post and core involves strategic decision-making. This can be achieved through two primary methods: direct formation within the patient's mouth or indirect fabrication on a model. Each approach presents its own set of advantages and considerations. In the direct method, where the design is crafted within the patient's mouth, a unique challenge arises due to the inherent variations in root alignment. The creation of custom-made cast post and core is a multifaceted process that requires careful consideration of factors such as root alignment and anatomical intricacies. The utilization of inventive approaches, like the direct method presented here, showcases the ongoing advancements in restorative dentistry, ultimately leading to successful outcomes in challenging cases. In the present case report, a custom-made cast post and core was fabricated using a direct method.

Brown Tumor with Multiple Lesions as a Manifestation of Tertiary Hyperparathyroidism: A Case Report and Literature Review

Brown tumor is an uncommon focal lytic bone lesion, which is considered as an end-stage lesion of abnormal bone metabolism, caused by long-standing increased parathyroid hormone levels. It is a rare manifestation of hyperparathyroidism that is classified into three types, of which tertiary is the rarest. It can be found in any part of the skeleton, and in some cases, occurs in multiple bones and can be easily misdiagnosed as a metastatic tumor. Therefore, although uncommon, it should be generally considered as a differential diagnosis with bone malignancy lesions, and particularly in patients with renal failure on long-term hemodialysis. In the present case report, a young patient with end stage renal disease presented with tertiary hyperparathyroidism revealed by multiple brown tumors of the pelvis and mandible. We recall through this observation the importance of clinical context, the complementary roles that different imaging modalities can play in different settings, and the relevance of measuring serum calcium and parathyroid hormone before the diagnosis of osteolytic bone lesions.

Fatal upper aerodigestive tract obstruction in an East Asian finless porpoise (Neophocaena asiaeorientalis sunameri): findings in post-mortem computed tomography.

The present case report aims to outline the post-mortem findings of an East Asian finless porpoise with upper aerodigestive tract obstruction using different post-mortem computed tomography (PMCT) visualization techniques and discusses the potential cause of death of this individual. A dead-stranded adult male East Asian finless porpoise was recovered from the Northern coast of Jeju Island, Republic of Korea. The carcass was frozen in Jeju National University within 2h upon first reported. The PMCT examinations were performed at 120 kVp, 200 mAs with a section thickness of 1mm. The scan field of view (sFOV) was set to 400mm. Four image rendering techniques, including multi-planar reconstruction, three-dimensional volume rendering, perspective volume rendering, and minimum intensity projection technique, were used to aid the diagnosis of upper aerodigestive tract obstruction in the stranded finless porpoise. Conventional necropsy was performed to provide a complete necropsy report. Using PMCT, a Sebastidae of 24cm measured length was found to be lodged in the left pharyngeal food channel and esophagus of the finless porpoise. Hard rays of the pectoral fin of the lodged fish have impaled the esophageal mucosa. Fishing gear was found to embed at the dorsal side of the lodged fish. The trachea was compressed ventrally and the arytenoepiglottic tube opening has been narrowed, which may precipitate to the finless porpoise difficult breathing. Pulmonary hyperinflation, pulmonary edema, pneumothorax, pneumopericardium, and pneumorrhachis were observed. This case report represents the first documentation of potential radiological indicators of upper aerodigestive tract obstruction in the East Asian finless porpoise using PMCT. Spatial location of the lodged item could be rendered in situ as the time of death. It has demonstrated that PMCT could provide objective measurements to adjunct the necropsy findings in diagnosis of fatal aerodigestive tract obstruction in stranded cetaceans.

Autonomous Dental Implant Robotic System Utilization for Implant Placement and Transcrestal Sinus Elevation Using Osseodensification: A Case Report.

Robotic systems have revolutionized various industries, and dentistry is no exception. Recently, due to the robust advancements in artificial intelligence and technology, there has been a significant evolution of dental robotic systems, ranging from surgeon controlled, robot-assisted operations, to more autonomous processes. The present clinical case report describes a 1-year follow-up of the successful use of an autonomous dental implant robot system with an osseodensification (OD) protocol for implant osteotomy preparation, maxillary sinus elevation, and simultaneous implant placement at the maxillary second premolar site. A prefabricated provisional prosthesis was delivered immediately after implant placement, with final prosthesis delivery at 3 months. The findings from this report demonstrate the integration and clinical augmentation of more autonomous protocols in the field of implant dentistry using dental robots.

Contemporary Diagnostic Approach of Natal Teeth in Identical Twins Utilizing Advanced Imaging Techniques: QLF and CBCT Imaging

Eruption of teeth at birth or immediately after is a rare phenomenon. The presence of teeth at birth is called natal teeth. However, the etiology of natal teeth is not deterministic. The natal teeth can lead to various medical associated problems and is also associated with various folklores and misconceptions. The diagnosis of natal teeth with its medical management along with counseling of the parents and family members is very important. The present case report provides an insight to the management of natal teeth in identical twins with a brief review of literature. Quantitative light-induced fluorescence imaging and cone beam computed tomography analysis of the teeth have also been done and compared with that of the primary dentition indicating hypo-mineralized tooth structure with decrease in radiodensity of the natal teeth. The present paper is a value addition in alternative diagnostic methods as an adjunct in the diagnosis of natal teeth and differentiating between the natal teeth and primary teeth.

Novel Compound Heterozygous Mutations of the SLC12A3 Gene in Gitelman Syndrome with Growth Hormone Deficiency and Hypothyroidism

Introduction: Gitelman syndrome (GS) is an inherited kidney disease that causes an imbalance of charged ions in the body. SLC12A3 mutation is the predominant cause of GS. There are different known and unknown pathogenic mutations in SLC12A3. Case Presentation: In the present case report, an 8-year-old girl was referred to our pediatric endocrinology clinic for evaluation of short stature. Her height was 113 cm (-2.94 SD). Her growth hormone peak was 5.81 ng/mL. IGF-1 was lower than -2SD. Thyroid stimulating hormone was high. The blood potassium was 3.37 mmol/L. After 3 months of GH treatment, her blood potassium dropped further (3.01 mmol/L). The gene test results showed that there were two heterozygous mutations of the SLC12A3 gene: C.1456G>A (p.D486N) and c.1065_1072 delGCAGGG (p.A356Qfs*5), which her parents verified. Conclusions: Gitelman syndrome can be associated with growth hormone deficiency and hypothyroidism in addition to short stature, hypokalemia, and hypomagnesemia, and the underlying molecular mechanisms need to be explored in the coexistence of these three diseases. The experience, in this case, is that blood electrolytes should be checked monthly for the first three months after growth hormone treatment for short stature. Once the blood potassium level is low, much attention should be paid to further diagnosis to avoid misdiagnosis.