Yellowish Discoloration Of Skin Research Articles

NEONATAL JAUNDICE: AN OVERVIEW

Jaundice is the most common problem of newborns. Around 60% term and 80% preterm neonate develop neonatal jaundice during first week of life. Neonatal jaundice is defined as yellowish discoloration of skin and sclera. Icterus appear on face when serum bilirubin level exceeds 5mg/dl. This is called physiological jaundice. It is usually noticeable when the baby is 2 to 4 days old. Most of the time, it does not cause problems and goes away within 2 weeks. Symptoms may include excess sleepiness or poor feeding. Complications may include seizures, cerebral palsyor kernicterus. The condition affects over half of babies in the first week of life. Of babies that are born early about 80% are affected. Globally over 100,000 late-preterm and term babies die each year as a result of jaundice. The need for treatment depends on bilirubin levels, the age of the child, and the underlying cause.Treatments may include more frequent feeding, phototherapy, or exchange transfusions.In those who are born early more aggressive treatment tends to be required.Physiologic jaundice generally lasts less than seven days.

A literary review article on Agnikarma in Kamala

Jaundice is defined as a yellowish discoloration of skin, mucous membrane and sclera due to the deposition of bile pigment (bilirubin). It can be classified as pre-hepatic, hepatic and post hepatic jaundice. The causes of various forms of Jaundice are either acquired or congenital. The incidence of jaundice in India is 2.37-3.15 per 1000 population. Varied reasons result in jaundice. Some of them are medically managed whereas some require surgical interventions. The underlying causative factors and clinical manifestations in such conditions are similar to Kamala described in Ayurveda. Various treatment protocols have been mentioned by various Acharya in their respective Samhita. One among them is a handbook for an Ayurvedic physician from Andhra Pradesh, written by Basavaraju named as Basavarajiyam where he has mentioned Agnikarma in Kamala Vyadhi which is a unique practice that might help for early recovery of patients. Another famous book on Viddha and Agnikarma Chikitsa by Dr.R.B. Gogate from Maharashtra also mentions about similar kind of treatment. By considering all these, the present article is aimed at understanding the textual references of Agnikarma in Kamala.

Autopsy Based Prospective Study of Synthetic Cow Dung Poisoning (Yellow Sani Powder Poisoning)

Traditionally it is believed that cow dung has germicidal and insect repellent properties in the Indian Sub Continent.South Indian people have been using the natural cow dung for cleaning, lining and painting the courtyard andhouse premises. In this modern era, owing to the unavailability of natural cow dung, the people have resorted tousing synthetic dye (synthetic cow dung) which is called colloquially as “Manjal Sani Powder” in Tamil. Syntheticcow dung powder(Auramine) - a dye compound, even though legally banned, is till date easily available locallywith small shops and vendors. Aim of the present study is to explore the postmortem findings of Synthetic cowdung powder (sani powder) poisoning in Western Tamil Nadu i.e, Coimbatore, the Nilgiris, Tiruppur, Erodeand Karur districts, the study being conducted in the Department of Forensic Medicine, Coimbatore MedicalCollege.The following parameters were collected and analyzed: the deceased’s sex and age, Post mortem findings,histopathological and chemical analysis reports.A total number of 224 cases were analyzed. Most of the deceasedpersons are of age between 31 to 40years in females (38.8%) andbetween 41 to 50years in males (36.6%). Most ofthe deceased persons were males(78.1%). Postmortem findings of yellow cow dung poisoning were yellowishdiscoloration of skin. Internal findings noted were tongue yellow coated. All the internal organs were stainedyellow.Intense Vigil and Strict Enforcement of regulations for manufacturing and selling of synthetic dyes cansignificantly reduce the incidence of Synthetic Yellow Cow Dung(Saani) powder poisoning.

Debilitating Contractures of Hands in an Atypical Presentation of Juvenile Pityriasis Rubra Pilaris: A Rare Case Report

Introduction: Palmoplantar keratodermas (PPK) constitute a clinically and genetically complex group of cornification disorders characterized by defective epidermal differentiation leading to marked palmoplantar hyperkeratosis. Classically, keratodermas have been categorised as hereditary and acquired forms. Case Presentation: A 12-year-old male patient presented to our dermatology outpatient department with diffuse thickening and yellowish discoloration of skin over palms and soles since early childhood. He gradually developed progressive thickening and contractures of the fingers of both hands with functional impairment. No such history could be elicited in the family members. Dermatological examination showed bilaterally symmetrical thick hyperkeratotic fissured scaly plaques involving surface of entire palm with sharp demarcation at volar aspect of wrist. Similar plaques with yellowish hue were present over the soles with superficial fissures. The histopathological examination of skin biopsy specimen from the palm showed focal parakeratosis alternating with orthokeratosis in both horizontal and vertical directions (checkerboard pattern) with broadened rete ridges. The findings were consistent with pityriasis rubra pilaris (PRP). The patient improved with systemic and topical retinoids. Conclusions: This report focuses on the recognition of unusual presentations of PRP and emphasizes the importance of early diagnosis and timely treatment, which can avert the dreaded morbid and disabling complication of contractures.

Study of risk factor and feto-maternal outcome in pregnancy with jaundice

Jaundice is defined as yellowish discoloration of skin and mucous membranes due to increase in serum bilirubin levels. Jaundice is clinically visible when bilirubin level exceeds 3mg%, the normal level being 0.2-0.8%. Liver is one of the organs affected during pregnancy due to hormonal and metabolic changes. Metabolic, synthetic and excretory functions of the liver are affected by the increased levels of estrogen and progesterone levels in pregnancy. Aims And Objective: To study the etiology of jaundice and maternal outcomes in terms of termination, maternal complications and mortality and neonatal outcomes of pregnancy with jaundice. Materials and Methods: This is an observational cross-sectional study including 150 patients of pregnancy with jaundice carried out over 3 years (2019-2022) in a tertiary care hospital of Berhampur, Odisha. Liver function test like serum bilirubin total, direct and indirect, serum protein, albumin and globulin, serum transaminases, alkaline phosphate, CT, BT, CBC, Coagulation profile and viral markers were studied. Results: Patient were between age group of 25-30 years from lower socioeconomic status with maximum being primigravida. Around 52% of patients presented at a gestational age >38 wks. Around 68% of case had total bilirubin < 5 mg%.100% of patients presented with yellowish discoloration of sclera or urine. 54% of patients presented with severe preeclampsia and eclampsia, 36% patients landed in PPH. 57.33% patients delivered vaginally. Conclusion: Jaundice in pregnancy has adverse feto-maternal outcome. It should be managed as a team of Obstetrician in collaboration with Physician, Gastroenterologist, Anesthetist and Neonatologist. Improvement in health education, regular ANC, and early referrals result in early diagnosis and treatment of jaundice during pregnancy and reducing maternal and fetal morbidity and mortality.

AYURVEDIC MANAGEMENT OF BAHUPITTA KAMALA W.S.R. HEPATOCELLULAR JAUNDICEA CASE REPORT

In this era of industrialization and life-threatening competition brings drastically changes in our life style. Most often patient just comes with complaints of "feeling sick and tired". Later it gets diagnosed as kamala (Jaundice). The incidence of such disease is increasing day by day due to change in life style and Eating habits. Jaundice is a condition in which yellowish discoloration of skin, sclera, mucous membranes, excretions occur due to hyperbilirubinemia and deposition of bile pigments. In Ayurveda jaundice is described as Kamlaroga. Kamala has been described in detail along with its aetiology, pathogenesis, symptoms, complications and management also. The description of Hepatocellular jaundice is similar to Ayurvedic description of Kamala vyadhi. This is a case report of 52-year-old female having Bahupittakamala (jaundice), who was treated with some Ayurvedic herbs and Virechana like panchakarma. She got effective results with Ayurvedic Management.

A case report on Alagille syndrome and its clinical features

Alagille syndrome is a rare, chromosome dominant inherited complex disorder affecting varying organs like the liver, heart, kidneys, skeleton, and brain. lt invariably happens because of Notch signaling pathway defects, primarily as a result of JAG1 mutation (ALGS type 1), but it conjointly occurs seldom because of neurogenic locus notch homolog protein (NOTCH2) mutation (ALGS type 2). The symptoms and severity of Alagille syndrome can vary widely, often in the same family, from person to person. Some people may have mild forms, while others may have more severe forms. Blocking of bile flow from the liver (cholestasis), yellowish discoloration of the skin and mucosal membranes (jaundice), low body weight, and extreme itching (pruritis) are the common symptoms, which often occur within the first three months of life. In this current study, we tend to report a case of 14 years old female child who was hospitalized with characteristic facial features like a broad forehead, yellowish discoloration of sclera and skin, posterior embryotoxon, intense itching, dry, coarse skin, mild splenomegaly, mild hepatomegaly. She conjointly had a history of progressive neonatal jaundice with prominent skin lesions and edema. Therefore our study emphasizes and focuses mainly on understanding and identification of distinct features associated with this syndrome to aid better management in all cases.

Ayurvedic management of Koshtashrita Kamala (Hepatocellular Jaundice) - A Case report

Kamala is a type of Liver disorder mentioned in our classics. It is caused by vitiation of pitta with the signs and symptoms like Haridra netra (yellow eyes), twak nakha (yellowish skin and nails) and Dourbalya (weakness), based on these clinical features, it can be well understood under the purview of Jaundice. The condition where yellowish discoloration of skin and sclera of the eyes due to high level of serum bilirubin is known as Jaundice. The pitta present in the body aggravates due to specific diet and life style, attains sthana samshraya in koshta due to kha vaigunya, further causes dagdhatwa of Rakta and Mamsa this condition is known as Koshtashirita Kamala. A case presented with Peeta Netrata, Peeta Varnyata Mutra, Aruchi, Agnimandhya etc was diagnosed as Koshtashrita Kamala it was intervened successfully with Shodhana and Shamana oushadi with proper pathya for a period of 11 days. The effect of treatment was assessed based on improvement in clinical signs and symptoms along with Liver Function Test. There was significant improvement in the condition by 60% thus Kamala can be well managed by Ayurvedic intervention.

Clinical spectrum of obstructive jaundice: a descriptive crosssectional study

Objective. The objective of this study was to evaluate the clinical spectrum of obstructive jaundice in inflammation, stone disease, and malignancy. Methods. A descriptive observational study was done among 50 patients with the diagnosis of obstructive jaundice during the period 2012 to 2013. A detailed history and clinical examinations and radiological confirmation were done. Results. Among the participants, 74% participants had jaundice, 58% with vomiting as presenting complaints. Among benign cases, 60% were choledocholithiasis, 25% were common bile duct stricture, and 15% were choledochal cyst. Among malignant cases, 26.67% were periampullary carcinoma, 23.33% had carcinoma of the pancreas head, and 13.33% had D2 duodenal carcinoma. Conclusions. The etiology of obstructive jaundice was malignancy in the elderly male population. The most common presenting features were yellowish discoloration of skin and mucosa followed by vomiting and abdominal pain.

THE EFFECT OF LEHA KAMALA IN THE MANAGEMENT OF BAHUPITTA KAMALA A CASE STUDY

Kamala is described under Raktavaha Srotas & Yakrit-pliha is the mula sthan of Raktavaha Srotas. Acharya Charaka said that Kamala is next stage of pandu mainly cause due to frequently consumption of Ushna (hot), Tikshna (spicy) food i.e. Pittaprakopak Ahara (increasing level of Pitta) but Sushruta and Vagbhata have accepted Kamala (Jaundice) not only as one of the complications of Pandu Roga (Aneamia) but also in association of other diseases. Due to these factors vitiation of Pitta (bile), Rakta (blood) and Mamsa (muscles) Dhatu occurs. Symptoms like yellowish discoloration of skin (Twak pitata), sclera (netra pitata), urine (Mutra pitata), stool (Purisha pitata) etc. are clinical symptoms of Kamala. Ayurveda believes in treating disease at its root cause from within. The present article is a case report of 56 years old male, farmer by profession visited in OPD and then admitted in IPD of Dr. M.N. Agashe Dharmarth Rugnalalaya, Satara on 07/12/2020 having complaining of Netra pitata (icterus), Mutrapitata (Yellowish urine), Adhmana (pain in abdomen), Sakashta mutrapravrutti (painful micturition), Padashotha (Bipedal edema), Mukhapaka (Mouth ulcer) from last 4 days. He was on antihypertensive drug regularly. He was having Arsha (bleeding hemorrhoids), also having h/o Kamala 2 years ago. The patient was treated with Ayurveda management under IPD and then OPD basis for 3 weeks. This helps to achieve complete curative and prophylactic management of Bahupitta Kamala through Ayurveda.

3021 Recurrent Obstructive Jaundice from Iatrogenic Pancreatic Duct Stricture

INTRODUCTION: There is always an intrinsic risk of complications with ERCP. The most common early complication include pancreatitis, followed by infection, bleeding and perforation.1 Late complications include pancreatic ductal and parenchymal changes, stent migration and malfunction due to occlusion. Here we present a case of an elderly man with recurrent obstructive jaundice and underwent multiple ERCP. CASE DESCRIPTION/METHODS: An 81 years old man was admitted for two weeks history of dark brown urine, light brown colored stools and diffuse itching of the skin. His past medical history included HTN and HLD. He had admission for similar symptoms twice within last one year. On initial admission, he was noted to have obstructive jaundice picture with multiple gall stones, dilated intrahepatic ducts, CBD and pancreatic duct. He underwent ERCP with removal of multiple small gall stones and later underwent cholecystectomy with normal liver functions on follow up. He required sphincteroplasty on later admission. He denied fever, chills, abdominal pain, weight loss, nausea, vomiting, and changes bowel habits. He denied alcohol or any drug abuse. On physical examination, he was afebrile, and was found to have scleral icterus, yellowish discoloration of skin and excoriations in extremities. Laboratory investigation revealed worsening hepatic function with ALT 192, AST 140, ALP 779, GGT of 1098, total bilirubin of 11.3 and direct bilirubin of 8.1. Other blood test results were normal including WBCs, serum electrolytes, TSH, toxicology screen, kidney functions, viral hepatitis panel and coagulation profile. US abdomen showed dilated common bile duct to 18 mm, pancreatic duct and intrahepatic ducts. MRCP showed persistent chronic CBD dilated to 14 mm, pancreatic duct to 4 mm and marked intrahepatic biliary dilatation and a focal stricture was seen in proximal pancreatic duct. He underwent ERCP and was found to have ampullary stenosis. Sphincterotomy was performed. His signs and symptoms resolved on follow up visit. DISCUSSION: It is challenging to diagnose biliary strictures. Most pancreatic duct stricture are iatrogenic from operative trauma. Moreover, it is difficult to estimate the procedural complications as there is always an inherent bias and patient underreporting. However, ERCP is associated with fourfold increased rates of severe complications than other endoscopic procedures. To avoid these complications, the procedure should be performed by experienced provider and trend towards therapeutic approach as opposed to diagnostic approach.

Ayurvedic Management of Shakhashrita Kamala w.s.r. to Hepatocellular Jaundice: A Case Study

The Liver is a vital organ involved in the maintenance of metabolic functions and detoxification of the exogenous and endogenous challenges like drugs, viral infections and chronic alcoholism1. Liver diseases occur throughout the world irrespective of Age, sex, religion and race. According to WHO 46% of global diseases and 59% of the mortality is because of chronic liver diseases and almost 35 million people in world die because of chronic liver diseases2. In Ayurveda, liver disorders and there treatment modalities are very well described under the heading of “Kamala Vyadhi”.
 In this study, a case report of 70 yr old male having yellowish discoloration of skin, sclera, and urine. Anorexia (Aruchi), Nausea (hrullas), generalized debility (daurbalya), Dyspnea (Shwas kashtata) since 10-15 days. He was diagnosed as Shakhashrita Kamala and treated with classical Herbal and some Herbomineral preparations as described in Samhita. Significant result was found in the above mentioned symptoms.

A Study of Cord Blood Albumin as a Predictor of Significant Neonatal Jaundice

Background: Neonatal hyperbilirubinemia is the commonest abnormal physical finding during the first week of life and its early detection is essential for prevention of bilirubin encephalopathy. Early discharge of healthy term neonates is a com-mon practice due to various reasons. The commonest cause for readmission of a normal neonate during early neonatal peri-od is neonatal hyperbilirubinemia. Readmission causes considerable stress to the family members. Aims: To assess whether cord blood albumin level could be used to predict the occurrence of significant jaundice requiring intervention. Settings and Design: It is a prospective study undertaken in postnatal wards of a teaching hospital. Material and Methods: Cord blood albumin was estimated in 130 healthy term neonates and they were divided into 3 groups based on cord blood albumin levels as follows: Group 1 with albumin levels <2.8g/dl; Group 2 with albumin levels between 2.8 and 3.3 g/dl and Group 3 with albumin levels of > 3.3g/dl. All the enrolled neonates were followed up for 72 hours and observed for clinical jaundice based on yellowish discoloration of skin. Neonates with evidence of clinical jaun-dice were subjected to total serum bilirubin estimation and hour specific values were plotted on Bhutani’s charts. Results: Clinical jaundice was present in 100 neonates for whom serum bilirubin estimation was done. There was a signifi-cant negative correlation between cord blood albumin levels and total serum bilirubin. Out of 100 neonates with clinical jaundice, 19 received phototherapy for significant hyperbilirubinemia. While all neonates in Group 1 received phototherapy none in Group 3 received intervention which was highly significant (p value <0.0001). Conclusion: Cord blood albumin estimation helps in predicting the possibility of hyperbilirubinemia in healthy term neo-nates. Key words: Cord blood albumin, Neonatal hyperbilirubinemia, Phototherapy

Case Report: Myocarditis along with fulminant hepatic failure secondary to acute hepatitis E infection

Myocarditis, defined as the inflammation of myocardial tissue has many causes which may be viral, metabolic or bacterial in origin. In this case we report a patient aged 22 years who was admitted with presenting complains of loss of consciousness, generalized muscle rigidity and yellowish discoloration of skin. During the course of his hospital stay, patient developed signs ofmyocarditis and later died of hypotensive shock. Viral serology was positive for the presence of hepatitis E virus (HEV), a rare cause of myocarditis. HEV infection can range from asymptomatic disease course to fulminant hepatitis but in rare cases it has been found to be a cause of myocarditis. This is so far the sixth case of hepatitis E induced myocarditis.

Autoimmune Hepatitis: Diagnostic Dilemma When It Is Disguised as Iron Overload Syndrome

Elevated serum ferritin level is a common finding in iron overload syndrome, autoimmune and viral hepatitis, alcoholic and nonalcoholic fatty liver diseases. High transferrin saturation is not a common finding in above diseases except for iron overload syndrome. We encountered a challenging case of 73-year-old female who presented with yellowish discoloration of skin, dark color urine and dull abdominal pain. Initial laboratory tests reported mild anemia; elevated bilirubin, liver enzymes, and transferrin saturation. We came to the final diagnosis of autoimmune hepatitis after extensive workups. Autoimmune hepatitis is a rare disease, and the diagnosis can be further complicated by a similar presentation of iron overload syndrome. Markedly elevated transferrin saturation can simulate iron overload syndrome, but a liver biopsy can guide physicians to navigate the diagnosis.

English

BACKGROUND: Liver dysfunction is associated with protean manifestations in skin, nails and hairs. OBJECTIVE: To study cutaneous manifestations in liver diseases. METHODS & MATERIALS: The patients of liver disease of any etiology and either sex, from January 2010 to December 2010, presenting in the Department of Medicine, Department of Gastroenterology, Department of Dermatology and Venereal Diseases, Gandhi Medical College and associated Hamidia Hospital Bhopal, were enrolled in study. A comprehensive proforma was completed for every case which included careful history, cutaneous and systemic examination. RESULTS: Out of 100 patients, 66 were male and 34 were female. The most common cause of liver disease was hepatitis B virus infection (32% cases) followed by alcoholic liver disease (26% cases). Hepatitis C related liver disease (14 % cases), cholestatic disease (8% cases), and hepatocellular carcinoma (6% cases). Wilson’s disease (4% cases), 2% cases of autoimmune etiology and in 8% cases the etiology could not be identified. The most common skin manifestation observed was xerosis(78% cases) followed by pigmentary changes (70% cases) with guttate hypopigmentation being more common (48% cases) while hyperpigmentation (40% cases), oral lesions (46% cases), yellowish discoloration of skin and eyes (40% cases), pruritis (45% cases), striae distensae (36% cases), Taenia infection (29% cases), Petechiae, ecchymosis and bruise (19% cases), urticaria (18% cases), Xanthelasma (8% cases), dermatitis(7% cases) and vitiligo, dupuytren’s contracture and spider naevi (3% each). CONCLUSION: We conclude that there is a strong correlation between skin and liver disease and further studies could be undertaken to identify the patients where skin manifestations could be the first sign of liver disease INTRODUCTION: Chronic Liver Diseases are a leading cause of major health problems in developing countries and present as one of the most important cause of morbidity and mortality in India. Liver is the one of the most vital and second largest organ of the body, any dysfunction in the liver leads to pathological changes in the largest organ of the bodythe skin. There is a association between liver disease and skin which can be as Hepatobiliary disease causing skin manifestation in many ways1, 9, Liver diseases may cause skin changes, Liver and skin may be involved by the same pathological process, Skin disease may cause liver abnormalities, Liver may get damaged by drugs used to treat skin diseases. Often skin manifestations can be the first sign of liver disease1. Chronic Liver Disease can give rise to numerous extrahepatic disorders among which skin disease occupy a central place Jaundice, xerosis, pruritis, pigmentary changes, loss of pubic and axillary hairs, leuconychia, spider naevi, telangiectasias, striae distensae with dilated veins on abdomen, palmar erythema all are recognized sequelae of liver disease12, 14.

Obstructive Jaundice: The Kidney Can Do It!

Introduction: Obstructive jaundice is a common clinical problem that gastroenterologists encounter. We report a rare case of obstructive jaundice caused by right renal cyst and hydronephrosis due to obstructive proximal ureteric stone. Case: A 69-year-old woman presented with yellowish discoloration of skin and dark urine for 2 days. Patient was a resident at the rehabilitation center after drainage of septic arthritis of left hip. She had history of coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, stroke, dementia and cholecystectomy. On examination she had scleral icterus and mild tenderness in right upper abdominal quadrant. Rest of the examination was unremarkable. Laboratory data on admission was abnormal for total bilirubin 11.1 mg/dL (normal 0.2-1.1), alkaline phosphatase 2,020 IU/L (32-92), AST 207 IU/L (15-41), ALT 171 IU/L (14-54), amylase 700 U/L (24-121), lipase >400 U/L (22-51). A computed tomography (CT) scan of abdomen showed mild common bile duct (CBD) dilatation at 11 mm, cystic structure anterior to the CBD measuring 5.3 × 3.9 cm and 12 mm right proximal ureteric stone with right hydronephrosis and cystic changes within right kidney. Magnetic resonance cholangio-pancreaticography (MRCP) showed no filling defect within biliary tree, enlarged right kidney with multiple cysts and exophytic cyst of 4.4 × 3.3 cm at anterior aspect of right kidney creating a mass effect on second portion of duodenum and pancreatic head. This corresponds to cystic structure seen on CT scan. Urology recommended decompressing cystic structure under radiologic guidance. During course of hospitalization, patient's liver functions started improving before she received any intervention. Upon attempting decompression, her renal cyst appeared to be reduced in size relieving compression on the second part of duodenum with improvement of her liver functions. Patient did not need any procedure. Three months later, her liver functions were within normal limits. With her poor condition, patient denied any further invasive work-up. Discussion: Obstructive jaundice can be caused by extrinsic compression of the biliary system. Extrinsic causes include pancreatic pseudocysts or lymphomas. Renal lesions causing obstruction of the biliary system have been very rarely reported. Giant hydronephrosis and megaureter have been reported to cause obstructive jaundice. We present a rare case of obstructive jaundice caused by right renal cyst with hydronephrosis due to obstructive ureteric stone. Although our case improved spontaneously, drainage procedures should be considered in similar cases.

As Rare As It Gets — Gastric Plasmacytoma Presenting as Jaundice: A Case Report

Purpose: INTRODUCTION: Primary or secondary involvement of the GI tract by plasma cell dyscrasias is exceptionally rare. We hereby present the case report of a gastric plasmacytoma that had a unique and novel presentation of jaundice. CASE DESCRIPTION: A 68 y/o female with h/o HTN, recurrent DVT, and asthma presented with abdominal pain for two weeks. Pain was associated with nausea, occasional vomiting and yellowish discoloration of skin and sclera. She denied any weight loss or itching. Abdominal exam showed mild distension, hepatomegaly and right upper quadrant tenderness. Laboratory results showed creatinine 1.8 mg/dl, Hgb 6.1g/dl, MCV 112.8, platelet count 45000cells/cubic millimeter, albumin 2.5 g/dl, total bilirubin 4.0 umol/l, direct bilirubin 2.9 umol/l, ALP 209 U/L, AST 75 U/L and ALT 36 U/L. Chest X-ray showed an abnormal lesion on the right 6th rib. Abdominal ultrasound showed coarsened echotexture of the liver, gall bladder sludge, perihepatic ascites and no cholecystitis. MRCP showed nodular liver without any significant gallbladder or CBD findings. EGD showed a nodule at the incisura of the stomach and a non bleeding ulcer. Histopathology of the gastric nodule revealed hyperplastic foveolar polyp containing a nodular cluster of plasma cells. Immunohistochemistry was consistent with a nodular collection of predominantly lambda positive cells in the lamina propria diagnostic of gastric plamacytoma. Bone marrow biopsy and flow cytometry analysis were interpreted as marked cell dyscrasia, diffuse marrow infiltration with monoclonal IgG/lambda + plasma cells. Immunohistochemistry showed that 90-95% of the nucleated cells in the biopsy were CD138 positive. DISCUSSION: Multiple Myeloma (MM) involves GI tract only in about <5% of the cases. Gastrointestinal involvement rarely is the first or sole presenting symptom of extramedullary MM. It is either an incidental finding or manifests as a secondary system involvement. Liver is the most commonly involved site followed by the small intestine, pancreas, stomach, peritoneum and colon. Gastric plamacytoma has a varied endoscopic appearance of thickened folds, polyposis, ulcers and multiple nodules. Differential diagnoses include amyloidosis, poorly differentiated neoplasms, MALT lymphoma and GIST. Tissue pathology including flow cytomtery and immunohistochemistry play a vital role in diagnostic differentiation. Complete resection of the gastric lesion is usually recommended with or without combination with irradiation or chemotherapy. Gastric or any extra nodal involvement in a patient with multiple myeloma carries a poor prognosis.

Melanin and facial skin fluorescence as markers of yellowish discoloration with aging

Although one clinical sign of aging and/or photoaging is a yellowish discoloration of the facial skin, little is known about the cause of this change. In addition to the increase in the epidermal melanin content, it has been suggested that advanced glycation end products (AGEs), which are known to accumulate in photoaged skin, may affect this discoloration. The objective of this pilot study was to non-invasively investigate the roles of melanin and AGEs in this yellowish discoloration of the facial skin. We examined the spectral reflectance at the cheek in 40 healthy Japanese women of various ages (mean age, 38.1 years) using a reflectance spectrophotometer and a spectrofluorimeter. The degree of yellowish tint was evaluated in terms of b(*). The amount of melanin in the skin was evaluated by calculating the melanin index (MI) A(640)-A(670) [A(lambda): log(10) (1/reflectance) at a wavelength of lambda]. The amount of AGEs was roughly evaluated using the AGEs index, which is thought to linearly correlate with the amount of intrinsic fluorescence markers irrespective of the concentration of melanin and is defined as follows: AGEs index=I(5)/SQR (I(1)xI(2)). In this equation, the intensities of reflectance are I(1) at an excitation wavelength of 335 nm, I(2) at an emission wavelength of 390 nm and I(5) at 390 nm under an excitation wavelength of 335 nm. Both b(*) and the AGEs index were significantly correlated with subject age (r=0.34, P<0.05 and r=0.68, P<0.0001, respectively). Significant correlations were also observed between MI and b(*) (r=0.63, P<0.0001) and between the AGEs index and b(*) (r=0.53, P<0.0005). However, no significant correlations were seen between MI and the AGEs index. The AGEs index does not appear to be influenced by the amount of melanin and may be utilized as an indicator of the amount of AGEs in the skin. AGEs are likely to play a role in the yellowish discoloration of skin with aging.

Breastfeeding Practices and Health-seeking Behavior for Neonatal Sickness in a Rural Community

The aim of the study was to evaluate the knowledge of mothers and grandmothers regarding breastfeeding and health-seeking behavior for neonatal sickness in a rural community. A cross-sectional survey, using a triangulation of qualitative (focus group discussion) and quantitative (structured questionnaire) methods was carried out. Although most of the grandmothers and mothers believed in early feeding within 2 h of delivery, they often administered prelacteal feeds such as ghutti and honey. Colostrum was considered beneficial. Most respondents believed that ghutti, water, or both should be given along with breastmilk. Diluted buffalo milk was the preferred choice if supplementation was required. It was thought that weaning should be introduced after 6 months of life. Mothers preferred to give dalia and khichri as the initial weaning food compared to roti and dal water by grandmothers. Both grandmothers and mothers felt that a baby who was playful and not crying excessively was usually healthy. Most of the respondents described the normal pattern of breathing, feeding, urination, and defecation adequately. Most of the grandmothers and mother's felt that by touching forehead and limbs of baby could reliably assess temperature. Refusal to feed was considered as a marker of a sickness by most grandmothers and mothers. However, they also believed that health-seeking for poor feeding could be delayed for 1 day. Respiratory distress was described by the presence of fast respiration, chest retractions, or noisy breathing. Most respondents did not know how to assess cyanosis or seizures. Jaundice was descried as yellowish discoloration of skin, eyes, and urine. Failure to pass urine for 4-6 h bothered most of the respondents. The first response to illness was home remedies. The choice of healthcare was unqualified village practitioners followed by government hospital. Knowledge regarding desirable breastfeeding practices was inadequate and quite a few inappropriate beliefs were widely prevalent. Although knowledge regarding sickness was present, health-seeking from qualified providers was considerably delayed with most respondents preferring village practitioners to government hospitals.