for mail.pmd 28 introduction: the thyroid hormones maintain the various metabolic functions by stimulating the o2 consumption in most of the cells of our body and are also necessary for their normal growth and maturation. the thyroid gland though is not essential for life; its absence causes mental and physical growth retardation. it may be also due to some intrinsic disorders in thyroid or pituitary or hypothalamus.13 the investigators studied nerve conduction parameters in hypothyroid patients to observe the incidence of neuropathy and functional status of peripheral nerves in thyroid deficiency. 4-6 most of them had shown that deficiency of thyroid hormones cause motor neuropathy by affecting different peripheral nerves but more commonly the median nerve. the common nerve conduction parameters done by the investigators include motor neuropathy in hypothyroidism: clinical and electrophysiological findings sabina yeasmin1, noorzahan begum2, shelina begum3 1associate professor of physiology, dhaka community medical college, dhaka. 2professor and chairman, department of physiology, bangabandhu sheikh mujib medical university, 3professor, department of physiology, bangabandhu sheikh mujib medical university, shahbagh, dhaka abstract: background: hypothyroidism is a clinical condition associated with low levels of thyroid hormones with raised tsh. peripheral neuropathy may be associated with hypothyroidism which usually develops insidiously over a long period of time due to irregular taking of drugs or lack of thyroid hormone replacement1. objectives: the present study was done to evaluate the clinical and electro-physiological findings in hypothyroid patients in order to evaluate the neuromuscular dysfunction as well as motor neuropathy. method: in this study, 70 subjects with the age range from 20 to 50 years of both sexes were included of whom 40 hypothyroids were taken in study group (b) with the duration of 6 months to 5 years and 30 healthy euthyroid subjects were taken as control (group a). on the basis of their tsh level, group b was further divided into group b1 with tsh level <60 miu /l (less severe) and group b2 with tsh >60 miu /l (severe group). the d latency and ncv for motor nerve function were measured by ncv machine in median and ulnar nerve for upper limb and in common peroneal nerve for lower limb. tt3, tt4 were measured by ria and tsh by irma method. all these parameters were measured on the day 1 (one) of their first visit. data were analysed statistically by anova and z test. result: both tt3, tt4 levels were significantly (p<0.01) lower in hypothyroids in comparison to those of control. diminished or absence of most of the deep tendon reflexes were found in all the hypothyroids. most of the patients (67.5%) showed significantly higher (p <0.01) motor distal latencies (mdl) with lower (p> 0.001) conduction velocities (mncv) and all these changes were more marked in group b2. conclusion: so, the study revealed that motor neuropathy may be a consequence of hypothyroidism. key words: hypothyroidism, neuropathy, electrophysiology [bsmmu j 2008; 1(1): 15-18] address of correspondence: dr. sabina yeasmin, associate professor of physiology, dhaka community medical college, dhaka. motor distal latencies (mdl), motor conduction velocities (mncv) in different peripheral nerves. motor conduction impairment of the nerve revealed by the increased mdl and decreased mncv in that nerve. in thyroid deficiency, the nerve conduction impairment is frequent in late stage of neuropathy and the common complaints are usually weakness of muscles of the limbs followed by the atrophy of the affected muscles supplied partially or completely by the nerves. 4-6 a good number of patients are suffering from thyroid deficiency which varies from mild to its severe form in our country.7 due to lower socioeconomic status and illiteracy, most of the patients were not aware about the consequences as well as the complications of delayed or irregular treatment. again, occurrence of neuropathy may have some relationship with the severity of thyroid deficiency 2; so they need to be more conscious about 29 complications of the disease. a few published data are available regarding the normal values of nerve conduction parameters of healthy bangladeshi population, 8 but no published data has yet to be found on these aspects in hypothyroid patients. therefore, the study has been done to find out the motor nerve conduction status of some peripheral nerves as well as to evaluate presence of motor neuropathy in hypothyroid patients. again, this study may also give a guideline to the physicians for proper and better management of hypothyroids and also to create awareness among this group of patients so that they can take early and regular treatment and thereby minimizes the occurrence of the neuropathy in hypothyroidism. methods: this study was carried out in the department of physiology, bsmmu, dhaka between january 2005 to december 2005. a total number of 70 subjects with the age range of 20 to 50 years of both sexes were included in this study, of whom 30 euthyroids (tsh=0.3-5miu/l) were included in group a (control) and 40 hypothyroids were included in group b (study group). they were further divided into group b1 consisted of 15 hypothyroids with tsh < 60 miu/l and group b2 consisted of 25 hypothyroid patients with tsh> 60 miu/l or severe group. most of the hypothyroid patients were under hormone replacement therapy. the duration of the disease varied from 6 months to 5 years. the objectives of the study were explained to each of the subjects and their written consents were taken. detailed medical history was taken regarding drug intake and their clinical examinations were done. the common features of motor nerve dysfunctions (weakness and atrophy of the muscles of the limbs) were searched for in all patients and all the informations were documented. the hormones were measured by ria14, 15 for tt3 and tt4 and irma16 for tsh. the nerve conduction studies were done by electrophysiological method with a standard ncv machine 5, 6. the statistical analysis was done by one way anova and z test. the study was performed at room temperature. results: all the parametric variables were expressed as mean (± sd). the comparison of the values were done among the different groups. in this study, the mean tt3 and tt4 were significantly lower in hypothyroids in comparison to those of healthy group but the differences were not statistically significant between two hypothyroid groups. (table-i). table-i the serum of tt3 and tt4 and tsh levels of the study subjects (n=70) groups tt3 tt4 (nmol/l) (nmol/l) a (n=30) 2.18 ± 0.53 129 ± 28.51 (1.40-3.02) (71.19-172) b1 (n=15) 1.31 ± 0.81 61.21 ± 29.81 (1.3-2.7) (40-170) b2 (n=25) 1.10 ± 0.85 54.4 ± 39.31 (0.45-1.25) (21-165) statistical analysis p value a vs b1 <0.01** <0.001*** a vs b2 <0.001*** <0.001*** b1vs b2 0.75 ns 0.889 ns results are expressed as mean ± sd; one-way anova (with post hoc test) was performed as the test of significance. figures in the parentheses indicate the ranges. group a=euthyroids (control group), group b1= hypothyroids with tsh level <60 miu/l, group b2= hypothyroids with tsh level >60 miu/l, ***= p < 0.001, **= p <0.01. n=number of subjects, ns=not significant. except diminished or absence of most of the deep tendon reflexes, the typical clinical features of motor neuropathy were absent in all patients. nerve study revealed, significantly higher (p < 0.01) distal latency (mdl) and lower (p<0.001) conduction velocity (mncv) in both of the hypothyroid groups in comparison to those of the control in median nerve (table ii). on the other hand, the differences of mdl were not statistically significant between two hypothyroids and also with that of control in ulnar nerve (table-iii). again, for common peroneal nerve, this value was higher in both the hypothyroids but it was statistically significant for severe group (table 4). however, mncv were significantly, lower in both the hypothyroids for all nerves. (tableii, iii, iv). all these parameters were statistically nonsignificant between two hypothyroid groups. again, this study also revealed that, 27 (67.5%) of the hypothyroid subjects showed the presence of neuropathy by abnormal ncv, of whom 18 (66%) of the subjects were in severe group and 9 (34%) were in less severe group. (table-v). bsmmu j vol. 1, issue. 1, july 2008 16 30 table-ii nerve conduction parameters for motor function of median (m) nerve (n=70) groups d latency (m sec) ncv (m/sec) a (n=30) 2.92 ± 0.338 62.33 ± 5.274 (2.50-3.50) (66.00-74.00) b1(n=15) 3.59 ±0.564 53.30 ± 5.046 (2.60-4.80) (43.00-61.00) b2 (n=25) 3.90 ±0.0887 53.68 ± 6.053 (2.60-6.20) (44.00-66.00) statistical analysis p value a vs b1 <0.010** <0.001*** a vs b2 <0.001*** < 0.001*** b1 vs b2 0.320 ns 0.0991 ns results are expressed as mean (± standard deviation); one way anova (post hoc test) was performed as the test of significance, the figures in parenthesis indicate range. group a = euthyroid control group, group b1 = hypothyroids with tsh level < 60 m iu/l, group b2 = hypothyroids with tsh level > 60 m iu/l, d latency = distal latency, ncv = nerve conduction velocity, *** = p <0.001, ** = p<0.01, n = number of subjects, ns = not significant. table-iii nerve conduction parameters for motor function of ulnar (u) nerve (n=70) groups d latency (m sec) ncv (m/sec) a (n=30) 2.48 ± 0.207 60.13 ± 4.790) (2.00-2.70) (53.00-68.00) b1 (n=15) 2.85 ±0.806 53.76 ± 5.309 (2.00-4.90) (45.00-60.00) b2 (n=25) 2.87 ±0.688 53.26 ± 5.722 (2.10-4.20) (45.00-65.00) statistical analysis p value a vs b1 0.113 ns <0.01** a vs b2 0.064 ns < 0.001*** b1 vs b2 1.00 ns 0.779 ns results are expressed as mean (± standard deviation); one way anova (post hoc test) was performed as the test of significance, the figures in parenthesis indicate range. group a = euthyroid control group, group b1 = hypothyroids with tsh level < 60 m iu/l, group b2 = hypothyroids with tsh level > 60 m iu/l, d latency = distal latency, ncv = nerve conduction velocity, *** = p <0.001, ** = p <0.01, n = number of subjects, ns = not significant. table-iv nerve conduction parameters for motor function of common peroneal (cp) nerve (n=70) groups d latency (m sec) ncv (m/sec) a (n=30) 3.60 ± 0.161 57.63 ± 4.230) (3.30-3.90) (50.00-67.00) b1 (n=15) 4.28 ±0.809 49.00 ± 3.273 (3.30-5.60) (43.00-57.00) b2 (n=25) 2.87 ±0.688 53.26 ± 5.722 (3.40-9.50) (40.00-56.00) statistical analysis p value a vs b1 0.06 ns <0.001*** a vs b2 <0.001*** <0.001*** b1 vs b2 0.435 ns 0.786 ns results are expressed as mean (± standard deviation); one way anova (post hoc test) was performed as the test of significance, the figures in parenthesis indicate range. group a = euthyroid control group, group b1 = hypothyroids with tsh level < 60 m iu/l, group b2 = hypothyroids with tsh level > 60 m iu/l, d latency = distal latency, ncv =nerve conduction velocity, *** = p <0.001, n = number of subjects, ns = not significant. table-v distribution of subjects by ncv (n=70) groups n normal ncv abnormal ncv no (%) no (%) a 30 27 90 3 10 b 40 13 32.5 27 67.5 *** b1 15 6 40 9 60 b2 25 7 28 18 72 statistical analysis was done by ‘z’ test as a test of significance. z = 6.243 group a=euthyroid (control) group, group b= hypothyroid group, group b1=less severe hypothyroids, group b2 =severe hypothyroids, ***=p<0.001 n=number of subjects, ncv=nerve conduction velocity. motor neuropathy in hypothyroidism: clinical and electrophysiological findings sabina yeasmin et al 17 31 discussion: the hypothyroid patients showed no remarkable clinical signs of motor neuropathy with the exception of a few like diminished or absence of most of the deep tendon reflexes but all the hypothyroids had significantly (p <0.01) lower tt3 and tt4 levels compared to euthyroids. nerve conduction abnormalities were observed in a significant number of hypothyroid patients by electrophysiological studies. however, the nerve conduction parameters in the control group were similar or nearer to normal reference values .4, 9,11-13 some other groups of investigators had also observed the slowing of nerve conduction velocities in different peripheral nerves but they did not mention about the individual values of the parameters like motor distal latency (mdl) and motor nerve conduction velocity (mncv). 5-6,14,16 both the hypothyroid groups showed higher motor distal latencies (mdl) with lower motor nerve conduction velocities (mncv) for median, ulnar and common peroneal nerves. again, the nerve conduction study revealed the predominant impairment in the median nerve among the three nerves as the differences of all the parameters were statistically significant between euthyroids and both the less severe and severe hypothyroids in this nerve. the investigators of different countries also mentioned about the similar involvement of median nerve1, 5, 6,9,14,16. the mechanisms involved in the development of neuropathy in hypothyroidism are not yet fully established but different investigators suggested that the weight gain in hypothyroids may be a contributory factor for neuropathy. in addition, the deposition of mucopolysaccharide or the myxedematous tissue may also lead to compression over the peripheral nerves and thereby results in swelling and degeneration of them4, 6. it has also been suggested that the thyroid hormones stimulate the mitochondrial respiratory activity to produce energy in the form of atp during aerobiosis under normal physiological condition. hormones also increase the atpase activity and consequently na+/k+ pump activity in this group of patients. therefore, deficiency of atp and reduced atpase and decreased na+/k+ pump activity cause subsequent alteration of pump dependent axonal transport and thereby may lead to peripheral neuropathy14. decrease glycogen degradation may also leads to energy deficit in hypothyroidism 5,6,14,16. though the neuropathy due to compression and the peripheral neuropathy due to axonal degeneration are not fully distinguished, most likely, there may be a combination of both these two factors, which results in the development of peripheral as well as the motor neuropathy in hypothyroidism 4. therefore, this study revealed that motor neuropathy is not an uncommon manifestation in patients suffering from hypothyroidism even in our population. references: 1. dyck pf, lambert eh. poly neuropathy associated with hypothyroidism. j neuropathol exp neurol 1970; 29: 631-658. 2. edwards crw, toft ad, walker br. endocrine disease. in: haslett c, chilvers e r, hunter j a a, boon n a. (editors). davidson’s principles and practice of medicine. london: harcourt brace and company; 1999; pp 559-575. 3. ganong wf. review of medical physiology. 21nd ed. boston : mc graw hill; 2003. 320p. 4. preston dc. electromyography and neuromuscular disorders, clinical electrophysiological correlations. 1st ed. usa: butterworthheinemann; 1998. 561p. 5. rao sn, katiyar bc, nair krp, misra s. neuromuscular status in hypothyroidism. acta neurol scand 1980; 61:167-77. 6. shirabbe t, tawara s, tetrao a, araki s. myxedematous polyneuropathy: a light and electron microscopy study of peripheral nerve and muscle. j neurol neurosurg psychiatry 1975; 38: 241-47. 7. record from the thyroid clinic, nuclear medicine and ultrasound centre, dmch, dhaka. 8. sultana s. some aspects of electrophysiological changes of peripheral nerves in diabetic patients of different duration [m phil thesis] [dhaka]: bangabandhu sheikh mujib medical university; 2003. 114 p. 9. total triiodothyronine (t3) radioimmunoassay kit (pr) imk422 [manual] 2005, department of isotope. china institute of atomic energy, beijing. 10. total thyroxine (t4) radioimmunoassay kit (pr) imk-419 [manual] beijing atom hightech co ltd., beijing. 2005. 11. tsh immunoradiometric assay kit imk-432 [manual], beijing atom hightech co ltd. , beijing2005 12. kimura j. electrodiagnosis in diseases of nerve and muscle: principles and practice. 2nd ed. philadelphia : f.a. davis; 1989. 103 p. 13. misra uk, kalita j. late response clinical neurophysiology; nerve conduction, electromyography and evoked potentials. 1st ed. new delhi : churchill livingstone pvt ltd. 1999. 20 p. 14. nemni r, bottacchi e, fazio r, et al. poly neuropathy in hypothyroidism: clinical, electrophysiological and morphological findings in 4 cases. j neurol neurosurg psychiatry 1987; 50: 14541460. 15. palumbo cf, szabo rm, olmsted sl. the effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome. j hand surg 2000; 734-739. 16. torres cf, moxley rt. hypothyroid neuropathy and myopathy: clinical and electrodiagnostic longitudinal findings. j neurol 1990; 237:271-274. 17. crevasse le, logue rb. peripheral neuropathy in myxedema. ann intern med 1959; 50: 1433-37. bsmmu j vol. 1, issue. 1, july 2008 18 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 vol. 2 no. 2, 2009 for serial.pmd introduction tuberculosis remains an important public health problem in bangladesh. isolated liver tuberculosis (ilt) is still considered a rare condition and hepatic tuberculosis is usually associated with an active pulmonary or miliary tuberculosis 1,2. liver involvement in tuberculosis is usually clinically silent. isolated hepatic tuberculoma (syn. nodular hepatic tuberculosis, macronodular hepatic tuberculosis) is the rarest form of local hepatic tuberculosis 3. tuberculosis presenting as an isolated liver tumor, without active pulmonary or miliary tuberculosis, or other clinical evidence of tuberculosis, is distinctly rare 4. in this report, we describe a rare case of isolated liver tuberculosis without pulmonary spread. case report a 32-year-old male patient was admitted with right upperabdominal pain and feeling of abdominal distention for a year. there was no history of exposure to tubeculosis. the patient was well and the vital signs were stable. physical examination showed local epigastric tenderness without hepatomegaly. laboratory data revealed normal serum hemoglobin level, a white blood cell count with slightly increased eosinophils, normal erythrocyte sedimentation rate, normal liver and renal function tests, and normal coagulation tests. tumor markers including alphafetoprotein, cea, ca 19-9 were normal.viral marker s: hbsag, anti hbc was also negative.fbs was high and pt was diabetic getting insulin.there was no radiological finding of tuberculosis in the chest x-ray. liver ultrasonography showed a rounded hypoechoic area measuring about 1.9cm seen in the right lobe and pancreatic calculi with mildly dilated main pancreatic duct[mpd].ercp was also done a case report: isolated liver tuberculosis zulfiqur rhaman khan1, md mohsen chowdhury2, mohammad saif uddin3, md. abu taher4 1professor, 2associate professor, 3medical officer, 4assistant professor, department of surgery, bangabandhu sheikh mujib medical university abstract isolated liver tuberculosis is still considered a rare condition and atypical clinical presentation challenges the clinical acumen of the treating physician. there is difficulty in reaching the correct preoperative diagnosis of a nodular hepatic tuberculosis that presents as a space-occupying lesion. it is usually unsuspected and confused with primary or metastatic carcinoma of the liver. in this report, we describe a rare case of isolated liver tuberculosis without pulmonary spread. keywords: s0l in liver . liver tuberculosis [bsmmu j 2009; 2(2): 88-89] address for correspondence: dr. zulfiqur rhaman khan, hepatobiliary surgery, associate professor department of surgery, bsmmu, email: khanzulfiqur@hotmail.com showing pancreatic calculi in the head region with mild dilation of the mpd. computed tomography of the abdomen showed multiple hypodense lesions in the right lobe of the liver (figures 1-2) with pancreatic stones and enlarged head of the pancreas suggestive of chronic pancreatitis with mass lesion on the head of the pancreas with possible hepatic metastasis.upper git endoscopy and colonoscopy revealed normal findings. fig.-1: axial ct scan showing a multiloculated, cystic mass in the right lobe of the liver. fig.-2: ct guided fnac of the liver ct guided fnac of the liver was done fig.-2. histopathological report revealed granulomatos tissue with areas of caseous necrosis and classic tubercles on the background of hepatocytes.no malignant cells were seen. the patient was discharged with anti tb including isoniazid 300mg/day, rifampicin 600mg/day, pyrazinamide 1500mg/day and ethambutol 1500mg/day were administered for two months and isoniazid 300mg/day and rifampicin 600mg/day were subsequently administered for four months. patient also was getting insulin and metformin for diabetes.after treatment, the patient was followed up for eight months without encountering any problem.follow up ct also revealed resolution stage. discussion: there are three forms of hepatic tuberculosis. diffuse hepatic involvement with pulmonary or miliary tuberculosis is the most common form seen in 50% to 80% of patients dying of pulmonary tuberculosis. diffuse hepatic infiltration without recognizable pulmonary involvement is the second form.our case was in the second form. the third very rare form presents as a focal/local tuberculoma or abscess. ilt is the rarest form of local hepatic tuberculosis 5. kok et al reported an overall incidence of 0.3% for isolated hepatic tuberculosis6. hepatic tuberculosis lesions that appear as masses larger than 2mm in diameter are referred to as macronodular and pseudotumoural tuberculosis. on the basis of imaging examinations alone, these lesions are virtually indistinguishable from many other focal lesions of the liver, such as hepatocellular carcinoma, metastases and hodgkin’s disease, so pathological examination is necessary for diagnosis 3. isolated hepatic tuberculosis results from tubercle bacilli gaining access to the portal vein from a microscopic or small tubercular focus in the bowel. the clinical presentation of ilt is so rare and atypical that it challenges the clinical acumen of the treating physician2. the difficulty is reaching a correct preoperative diagnosis of nodular hepatic tuberculosis that presents as a spaceoccupying lesion. it is usually unsuspected and confused with primary or metastatic carcinoma of the liver, as in our case. radiological findings of hepatic tuberculosis are not specific although multiple hypodense lesions have been described on ct scan in cases of macronodular tuberculoma of the liver 7.in our case we have also seen the same ct features. the radiologic diagnosis of hepatic tuberculoma is difficult and histopathologic diagnosis is required to distinguish tuberculosis from lymphoproliferative disorder, metastatic deposits and other granulomatous disease like sarcoidosis and fungal infection. establishing the diagnosis is not easy, especially if there is no history of previous tubeculosis exposure. the definitive diagnosis could be done with tests on histological and bacteriological evidence of tuberculosis. the histological picture of hepatic tuberculoma is usually that of a large epitehloid tumour composed of conglomerate tubercles with central caseation necrosis. langerhans-type gaint cells may be found in the granuloma and are surrounded by lymphohistiocytic cells, plasma cells and eosinophils 8. in view of the nonspecific presentation and imaging appearance of the disease, a high index of suspicion is required to obtain a preoperative diagnosis 9. in this case, the diagnosis was established by usg guided fnac. a pcr assay can be done for identification of mycobacterium tuberculosis in liver biopsy specimens. the importance of establishing the correct diagnosis cannot be overstated, since untreated abdominal tuberculosis carries a 50% mortality rate 10,11. conclusion: preoperative diagnosis of isolated liver tuberculosis that presents as space occupying lesions is difficult. it is mostly confused with primary or metastatic carcinoma of the liver. references: 1 . bangroo ak, malhotra as. isolated hepatic tuberculosis. jiaps 2005; 10: 105-107. 2 . singh d, singh s, raut sb, karmarkar sj. isolated liver tuberculosis: a case report. pediatr surg int 2004; 20: 727-28. 3 . vimalraj v, jyotibasu d, rajendran s. macronodular hepatic tuberculosis necessitating hepatic resection: a diagnostic conundrum. can j surg 2007; 10;50. 4 . nampoory mr, halim mm, shreedharan r, al-sweih na, gupta rk, costandi jn. liver abscess and disseminated intravascular coagulation in tuberculosis. postgrad med j 1995;71:490-92. 5 . purl as, nayyar ak, vij jc. hepatic tuberculosis. ind j tub 1994; 41: 131-34. 6 . kok ky, yapp sk. isolated hepatic tuberculosis: report of five cases and review of the literature. j hepatobiliary pancreat surg 1999; 6: 195-98. 7 . kumar v, pandey d. isolated hepatosplenic tuberculosis. hepatobiliary pancreat dis int 2008; 7: 328-30. 8 . tan tc, cheung ay, wan wy, chen tc. tuberculoma of the liver presenting as a hyperechoic mass on ultrasound. br j radiol 1997; 70: 1293 -95. 9 . debnath pr, tripathi r, kandpall d, kumar b, malik e, sharma sb. isolated tubercular liver abscess in children treated with percutaneous isoniazid infusion. indian j tuberc 2007; 54: 149-51. 1 0 . chen hc, chao yc, shyu ry, hsieh ty. isolated tuberculous liver abscesses with multiple hyperechoic masses on ultrasound: a case report and review of the literature. liver int 2003; 23: 346-50. 1 1 . alcantara-payawal de, matsumura m, shiratori y. direct detection of mycobacterium tuberculosis using polymerase chain reaction assay among patients with hepatic granuloma. j hepatol 1997; 27: 620-27. bsmmu j vol. 2, issue 2, july 2009 89 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 vol. 2 no. 2, 2009 for serial.pmd introduction: cocoon is a covering of silk threads that some insects make to protect themselves before they become adult. abdominal coccon is a peculiar morphologic entity characterized by encasement of part or the whole of the small bowel by a fibrocollagenic cocoon like case 1-3. it is a rare condition of unknown aetiology that primarily affects adolescent girls living in tropical and subtropical regions4. abdominal cocoon usually presents as recurrent acute or sub acute intestinal obstruction with or without a mass 3. about 60 articles dealing with this topic was found in medline search till date 2. here we report a case of abdominal cocoon in a young girl with history of intermittent colicky pain in right lower abdomen for about a year. clinically it was diagnosed as recurrent appendicitis. laparotomy was done and resection of the lump was performed and the specimen was sent for histopathology with a provisional diagnosis of intestinal tuberculosis. case report a 15 year old girl from narsingdi presented with a history of intermittent colicky pain in the right lower abdomen for one year. the pain aggravated after taking food. there had been 7 to 8 episodes of similar attack of pain during last one year which was relieved by taking medications (homoepathic drugs). she had a history of weight loss and occasional fever. during her last attack she consulted a local physician. clinical diagnosis was recurrent appendicitis. on examination she was found anaemic, pulse rate was 68/min and blood pressure was 100/70 mm hg. routine laboratory tests revealed a total leucocyte count of 6500 cell/cmm, abdominal cocoon – a case report with short review of literature tamanna choudhury1, mohammed kamal2 1associate professor, 2 professor & chairman, department of pathology, bangabandhu sheikh mujib medical university, dhaka abstract: abdominal cocoon is a rare entity where there is encapsulation of the small bowel by a fibrous membrane causing clustering of the bowel. the exact aetiology is unclear. we report a case of a 15 year old girl with a history of recurrent colicky abdominal pain in the right lower abdomen. clinical diagnosis was recurrent appendicitis. she underwent laparotomy for appendicular lump. histopathological examination of the resected lump grossly and histologically revealed the features of abdominal cocoon. key words: abdominal cocoon, sclerosing encapsulating peritonitis, small bowel. [bsmmu j 2009; 2(2): 81-84] case reports address of correspondence: dr. tamanna choudhury, associate professor, department of pathology, bangabandhu sheikh mujib medical university, dhaka, e-mail: ctamanna317@yahoo.com polymorphonuclear leucocytes were 69% and lymphocytes were 29%. her haemoglobin was 12.6gm/dl and esr was 10 mm and a normal urine analysis. ultrasonogram (usg) of the whole abdomen was done. there was a mixed echogenic lump in the right iliac region (64mm x 43mm) which gave an impression of appendicular lump. the whole abdomen was otherwise normal. she was admitted to a local clinic and underwent laparotomy in april 2009. on opening the abdomen a huge mass was found in the terminal ileum. resection of the terminal ileum with caecum and proximal part of the ascending colon was done followed by ileocolonic anastomosis, as stated in the operation note. recovery of the patient was uneventful. the surgical specimen was sent to the department of pathology, bsmmu with a provisional diagnosis of intestinal tuberculosis.on gross examination there was a long loop of intestine measuring 26 cm in length. central portion of the loop was dilated measuring 10 cm in diameter (fig.-1), located 10cm from the proximal resection margin fig.-1: gross view of the resected intestine review of literature abdominal cocoon is a rare condition 1,3-7 that refers to total or partial encapsulation of the small bowel by a thick fibrocollagenous membrane or cocoon like membrane and adhesions causing clustering of the bowel with local inflammatory infiltrate leading to acute or chronic bowel obstruction 1,3,6-8. occasionally the large bowel, stomach, liver or other abdominal organs may be involved 2,3,6 . historical background abdominal cocoon was first described in 1907 by owstchinnikow as peritonitis chronica fibrosa incapsulata 3. brown et al. 9 described the condition as a complication of long term treatment with beta adrenergic blocking agents. the abdominal cocoon was first described and named in 1978 by foo et al.10abdominal cocoon, a rare condition primarily affects young females from tropical and subtropical regions 4,7 but adult case reports from temperate zones and in both genders can be encountered in literature 3,4,7. a medline search revealed that in english literature approximately 47 cases have been reported till 2006 4 . another study reported about 60 articles dealing with this topic found in medline search 2.this condition has been variously described as sclerosing peritonitis, encapsulating peritonitis or sclerosing encapsulating peritonitis (sep) 5,11 . aetiological factors abdominal cocoon is of two types primary or idiopathic and secondary 2,3,5,12. the primary or idiopathic abdominal cocoon is a rare condition mainly described in young girls from tropical regions2,3,12. to explain the aetiology and the formation of the membrane of this condition a number of hypotheses have been proposed. these include retrograde menstruation with a superimposed viral infection 1,3,4,8,10 retrograde peritonitis via fallopian tubes, and cell mediated immunological damage incited by gynaecological infection13. however none of these hypotheses explain the characteristic age group, sex, and geographical distribution of this disease and there is no objective evidence to substantiate them 4. secondary abdominal cocoon has been reported following long term use of the beta blocker practolol 9,14,15 or associated with sarcoidosis, sle, liver cirrhosis, chronic ambulatory peritoneal dialysis (capd), intraperitoneal instillation of drugs, leiomyomata of the uterus, ovarian endometriosis16 or tumours of the ovary, tuberculous pelvic inflammatory disease 2,3,5,6,14. these conditions may predispose patients to peritoneal irritation and inflammation, which as a final effect leads to peritoneal fibrogenesis 3,6. fig.-2: cut section of the dilated part of the intestine and 6cm from the distal resection margin. caecum or ascending colon could not be identified. the serosa was apparently unremarkable. on opening the dilated portion showed multiple luminal structures clustered together and covered by thick fibrous tissue. majority had thickened mucosa resembling intestinal mucosa and few had thin mucosa (fig.-2). the average diameter of the luminal structures was about 2.5cm. three lymph nodes were found. multiple sections were given from the luminal structures including the lymph nodes. on microscopic examination the sections from the luminal structures revealed only lymphoid hyperplasia in the submucosa. there was moderate infiltration of chronic inflammatory cells in the serosa with fibrosis (fig 3). lymph nodes revealed features of reactive changes. there was no evidence of granuloma or malignancy. the diagnosis was ‘primary abdominal cocoon’. fig.-3: microscopic section of the intestinal wall shows lymphoid hyperplasia in the submucosa (h & e x 200). inset shows microscopic section of the serosa showing thickening with chronic inflammatory cell infiltration (h & e x400) abdominal cocoon – a case report with short review of literature tamanna choudhury & mohammed kamal 82 clinical features patients usually presents with features of acute/subacute small bowel obstruction, symptoms of chronic obstruction, progressive nausea and vomiting, weight loss and/or colicky pain associated with an abdominal lump 2-4,6,7,16. a preoperative diagnosis is almost never made and the non specific and intermittent symptoms may result in delay in diagnosis 4. most cases are diagnosed incidentally at laparotomy although a preoperative diagnosis is purported feasible by a combination of barium follow through (concertina pattern or cauliflower sign and delayed transit of contrast medium)3,5-7 and computed tomography of abdomen may be more diagnostic 3demonstrating small bowel loops congregated to the center of abdomen encased by a soft tissue density mantle, peritoneal thickening, calcification, peritoneal enhancement, small bowel tethering and loculated fluid collection 1,5,6,8. usg may show clumping of bowel loops with the bowel surrounded by a thick rim of hypoechoic tissues 6. however, preoperative diagnosis of abdominal cocoon requires a high index of clinical suspicion 7, supported by clinical data and image findings indicative of the condition16. clinicians must rigorously pursue a preoperative diagnosis, as it may prevent a ‘surprise’ upon laparotomy and unnecessary procedures for the patient such as bowel resection 7. most cases were diagnosed when a laparotomy was performed for obstructive symptoms 9. the characteristic findings is that of the encasement of the whole or part of the small bowel by a thick shiny membrane, aptly simulating cocoon. the loops of the small bowel remain stuck together by filmy soft adhesions separated easily by blunt or sharp dissections from the cocoon4,12. histopathological examination of the encapsulating membrane shows thickened fibrocollagenous tissue with or without lymphocytic and plasma cell infiltration 2-5. regional lymph nodes demonstrate non specific reactive hyperplasia 10,12. the final diagnosis of abdominal cocoon is usually made based on intraoperative and histological findings 1. management as conservative management often fails 3 surgery remains the cornerstone in the management of abdominal cocoon 4. surgery includes careful dissection and excision of the thick sac with release of small intestine and adhesiolysis of small bowel loops 3-5,7,16 which leads to complete recovery 1,4,7. resection of bowel is unnecessary and increases morbidity and mortality and is indicated only if it is nonviable 7. differential diagnosis abdominal cocoon or sclerosing encapsulating peritonitis (sep) may be confused with a developmental anomaly where the whole of the small bowel is encased in a thin membrane. the clinical symptoms differ from those of the abdominal cocoon in that the patients are mostly asymptomatic and the findings are incidental and late in life5,12. prognosis the prognosis of abdominal cocoon after surgery seems excellent and no recurrence has been described4,17,18. conclusion: although abdominal cocoon is a rare entity, it can be diagnosed preoperatively as it may have a distinct appearance on barium follow through and ct of the abdomen and also with high index of clinical suspicion. in this case however only usg was done which gave an impression of an appendicular lump. this case report intends to raise an awareness and enable earlier preoperative diagnosis and prevent unnecessary bowel resection as careful dissection and excision of the thick sac with release of small intestine and adhesiolysis of small bowel loops leads to complete recovery. references: 1 . ranganahtan s, abdullah bjj, sivanesaratnam v. abdominal cocoon syndrome, case report. jhk coll radiol 2003;6:2012 0 3 . 2 . kaushik r, punia rps, mohan h, attri ak. case report. tuberculous abdominal cocoona report of 6 cases and review of literature. world journal of emergency surgery 2006;1: 18. published online 2006 june 27. available from: http:// www.wjes.org/content /1/1/18. 3 . hasan mfm, muhsin oma, abassi aa, youssufani r. abdominal cocoon: a report of three cases. the middle east journal of emergen cy medicine 2007 september; 7(2). available from:http://www.hmc.org.qa/mejem/sept2007/ edited/ case2.htm. 4 . devay ao, gomecili i, korokluoglu b, kusdemir a. an unusual and difficult diagnosis of intestinal obstruction: the abdominal cocoon. case report and review of literature. world journal of emergency surgery 2006;1:8. available from http:// www.wjes.org/content/1/1/8. 5 . demir mk, akinci o, onur e, koksal n. case 108: sclerosing encapsulating peritonitis. radiology 2007;242:937-939. 6 . hosein hh, quane lk, cohen aj. abdominal cocoon. applied radiology 2003; 32(10). available from http://www. medscape.com/viewarticle/464849_print 7 . seramifidis c, katsarolis i, vernadakis s. idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon). bmc surgery bsmmu j vol. 2, issue 2, july 2009 83 2006; 6:3. available from http://www.biomedcentral.com/ 1471-2482/6/3. 8 . deeb ls, mourad fh, el-zein yr, uthman sm. abdominal cocoon in a man: preoperative diagnosis and literature review. j clin gastroenterol 1998 mar; 26(2):148-50. 9 . brown p , read ae. , baddeley h. , davies j.d. , mcgarry j. sclerosing peritonitis an unusual reaction to a â-adrenergic blocking drugs (practolol). lancet 1974; 2:1477-81. 1 0 . foo kt, ng kc, rauff a, foong wc, sinniah r. unusual small intestinal obstruction in adolescent girls: the abdominal cocoon. br j surg 1978; 65(6):427-30. 1 1 . cohen o, abrahamson j, ben-ari j, frajewicky v, eldar s. sclerosing encapsulating peritonitis. j clin gastroenterol 1996 jan; 22(1):54-7. 1 2 . sieck jo, cowgill r, larkworthy w. peritoneal encapsulation and abdominal cocoon. case reports and a review of the literature. gastroenterology 1983 jun; 84(6):1597-1601. 1 3 . narayanan r, kabra s.g , bhargava b.n, sangal b.c. idiopathic sclerosing encapsulating peritonitis. lancet 1989; 334: 127 – 129. 1 4 . lalloo s, krishna d, maharajh j. abdominal cocoon associated with tuberculous pelvic inflammatory disease. case report. the british journal of radiology 2002; 75: 174-176. 1 5 . myllärniemi h, leppäniemi a . peritoneal fibrosis due to practolol. scanning electron microscopical and histological observations. acta chir scand 1981; 147(2): 137-42. 1 6 . santos vm, barbosajer, lima shm, porto as. abdominal cocoon associated with endometriosis. case report. singapore med j 2007; 48(9): 240-242. 1 7 . kumar m, deb m, parshad r. abdominal cocoon: report of a case surg today. 2000; 30(10): 950-3. 1 8 . wei b, wei hb, guo wp, zheng zh, huang y, hu bg and huang jl. diagnosis and treatment of abdominal cocoon: a report of 24 cases. american journal of surgery 2009 sep; 198(3): 348-53. abdominal cocoon – a case report with short review of literature tamanna choudhury & mohammed kamal 84 for mail.pmd 11 effects of oral supplementation of vitamin e on fragility of rbc in hemolytic anemic patients with g6pd deficiency nayma sultana1, noorzahan begum2, shelina begum3, sultana ferdousi4, taskina ali4 1assistant professor, department of physiology, sir salimullah medical college, dhaka, 2professor and chairman, department of physiology, bangabandhu sheikh mujib medical university, dhaka, 3professor, department of physiology, bangabandhu sheikh mujib medical university, dhaka, 4assistant professor, department of physiology, bangabandhu sheikh mujib medical university, dhaka. abstract: background: vitamin e has role in maintaining the integrity of red cell membrane by preventing oxidation of polyunsaturated fatty acids and thereby protects cells from oxidative stressinduced lysis in g6pd deficiency, which can be reflected by changes in osmotic fragility of rbc and some absolute values like mcv, mch & mchc. objective: to observe the effects of vitamin e supplementation on fragility of rbc in order to evaluate role of this antioxidant vitamin in reducing chronic hemolysis in g6pd deficient patients. methods: for this, a total number of 102 subjects with age ranged from 5 to 40 years of both sexes were included in the study. among them 68 were g6pd enzyme deficient patients, of whom 34 were in supplemented group (study group) and 34 were in non-supplemented group (control group). the supplemented group received vitamin e supplementation for 60 consecutive days at a dose of 800 iu/day for adult and 400 iu/day for children < 12 years (in a divided dose i,e. 4 times daily). age and sex matched 34 apparently healthy subjects with normal blood g6pd level were taken to observe the base line data (healthy control) and also for comparison. all the g6pd deficient patients were selected from out patient department (opd) of hematology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh during the period of july 2005 to june 2006 and all the healthy subjects were selected from personal contact. blood g6pd level, osmotic fragility of rbc were measured by standard techniques and mcv, mch, and mchc were obtained by calculation. all the parameters were measured on day 1 (one) of their first visit and also were on day 60 in deficient group. data were compared among the deficient groups, also in supplemented group just before and after supplementation. analysis of data was done by appropriate statistical method. results: mean starting and completing points of osmotic fragility of rbc were significantly higher but mcv, mch, mchc were significantly lower in patients suffering from hemolytic anemia due to g6pd deficiency in comparison to those of the healthy control. after supplementation with vitamin e starting and completing points of osmotic fragility of rbc were significantly decreased whereas, mcv, mch, mchc were significantly increased towards those of healthy control in supplemented group of patients in comparison to those of their pre-supplemented (day-1) and non-supplemented groups both on day 1 and day 60. conclusion: from this study it may be concluded that, disturbances of some of the hematological parameter like higher osmotic fragility of rbc and lower mcv, mch, mchc occur in g6pd deficient hemolytic anemic patients, which returned towards normal after supplementation of vitamin e, which clearly indicates the role of this anti-oxidant vitamin in maintaining red cell membrane integrity and thereby decreases the rate of hemolysis in this group of patients. so, vitamin e can be supplemented along with other drugs for better management of the patients. key words: osmotic fragility, g6pd, hemolytic anemia, vitamin e. [bsmmu j 2008; 1(1): 6-10] address for correspondence: dr. nayma sultana, assistant professor, department of physiology, sir salimullah medical college, dhaka, bangladesh, e-mail:nayma_sultana@yahoo.com introduction: glucose 6-posphate dehydrogenase (g6pd) deficiency is the most common clinically significant enzyme defect in human biology and the common clinical manifestation of this enzyme defect is hemolytic anemia 1 . acute hemolytic crisis may occur in g6pd deficiency due to some oxidative stress, such as intake of some anti-malarial drugs, ingestion of fava beans, various types of bacterial and viral infection2-4. hemolysis of rbc may also occur even without prior administration of drugs in g6pd deficiency 5-7. vitamin e is one of the major lipid soluble antioxidant. it prevents oxidation of polyunsaturated fatty acids and thus protects red blood cells from oxidative stress-induced lyses8. again, deficiency of vitamin e is a common feature in genetic anemia, including g6pd deficiency hemolytic anemia due to its increased consumption 8,9 . supplementation of vitamin e may have an important role in maintaining red cell membrane integrity by reducing osmotic fragility of erythrocyte10,11 and can minimize the 12 severity of hemolysis in g6pd deficient patients12. again, vitamin e supplementation can restore the required amount of vitamin e level in this group of patients, and thus may prevent hemolysis by improving red blood cells survival 5,6,13. normal red blood cell indices like mcv, mch and mchc may also be found in peripheral blood film by oral supplementation of vitamin e 11 . an increase in osmotic fragility of rbc may occur in hemolytic anemia with g6pd deficiency 14 . mean corpuscular volume (mcv), mean corpuscular hemoglobin (mch) and mean corpuscular hemoglobin concentration (mchc) may also decrease in this group of hemolytic anemic patients 15,16. however the common clinical consequences of this enzyme deficiency are neonatal jaundice and sporadic hemolytic crisis2, can be minimized by vitamin e supplementation. in our country many people are suffering from hemolytic anemia due to g6pd deficiency. unfortunately, most of them are treated without knowing the actual cause. study of the changes in osmotic fragility of rbc and mcv, mch, mchc is important as it may reflect the hemolytic crisis in g6pd deficient patients. evaluation of supplementation of vitamin is equally important in these cases 10,11. in bangladesh there is lack of adequate information about deficiency of g6pd enzyme among the anemic patients. only one study regarding the hematological parameters of g6pd enzyme deficient patients has been reported in our country17. but no published data regarding effects of vitamin e supplementation in these g6pd enzyme deficient patients are available. for this, the present study was aimed at to observe some aspects of hematological parameters in g6pd deficient hemolytic anemic patients both before and after supplementation of vitamin e, in order to explore its role in preventing red cell lyses and thereby maintains the normal hematological status in these enzyme deficient patients. the output of the study may be helpful to create awareness about the deficiency of g6pd enzyme in anemic patients as well as the role of vitamin e in minimizing the risk of complications. moreover it can provide information to clinicians for better management of these patients. methods: the present prospective interventional study was carried out in the department of physiology, bsmmu, dhaka from july 2005 to june 2006. in this study, a total number of 102 subjects with age ranged from 5 to 40 years of both sexes were included. among them 68 were patients of hemolytic anemia with blood g6pd level below the normal reference range 18 , of whom 34 were in supplemented group (experimental group) and 34 were without supplementation and was considered as nonsupplemented group (control group). the supplemented group received vitamin e supplementation for 60 consecutive days at a dose of 800 iu/day for adult and 400 iu/day for children < 12 years; in a divided dose i,e. 4 times daily6,19. age and sex matched 34 apparently healthy subjects with normal blood g6pd level were taken to observe the baseline data (healthy control) and also for comparison. all the g6pd deficient patients were selected from out patient department (opd) of hematology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, and all the healthy subjects were selected from personal contact. blood g6pd level, osmotic fragility of rbc and red cell indices (mcv, mch, mchc) were done in all the subjects on day 1(one) of their 1st visit and in g6pd enzyme deficient groups of subjects also on day-60. data were compared among healthy control, supplemented, non-supplemented and also within supplemented groups just before and after supplementation. all the subjects belonged to middle and lower middle socio-economic status. patients with acute hemolytic episode or received blood transfusion in the last two months and β thalassemia trait were excluded from the study. the objectives and benefits of the study were explained to all the subjects to ensure their voluntary participation and a written informed consent was taken from each subject prior to the study. two (2) ml of blood was taken in an edta test tube for determination of erythrocyte g6pd level and the hematological parameters.. erythrocyte g6pd enzyme level was determined by spectrophotometric method 20 and the hematological parameters were estimated by standard laboratory technique21,22. all of these tests were done in the department of physiology, bsmmu, dhaka. data were expressed as mean + sd. independent-samples(unpaired) ‘t’ test and paired-samples ‘t’ test were done as the tests of significance wherever applicable. the statistical analysis was done by using spss programme version 12. p value <0.05 was considered as significant. results: mean erythrocyte g6pd levels were significantly (p<0.001) lower in g6pd enzyme deficient group of patients when compared to that of healthy control (tablei). the mean starting and completing points of osmotic fragility of rbc were significantly (p<0.001) higher in effects of oral supplementation of vitamin e on fragility of rbc in hemolytic anemic patients nayma sultana et al 7 13 both the g6pd deficient groups in comparison to those of healthy control group on day-1. after supplementation of vitamin e (i,e. on day-60) starting and completing points of osmotic fragility of rbc were significantly (p<0.001) decreased in comparison to those of their presupplemented (day-1) and also of non-supplemented groups both on day-1 and day-60 and returned almost toward the values of healthy control (table-ii). patients with g6pd deficiency had significantly (p<0.001) lower mcv, mch and mchc compared to those of healthy control. these values were increased significantly (p<0.001) toward the values of healthy control in g6pd deficient group following vitamin e supplementation. (table-iii). table-i mean (±sd) erythrocyte g6pd level in different study groups (n = 102). groups n u/1012 rbc u/g hb a 34 191 + 18.8 6.69 + 1.19 (161 – 226) (5.00 – 9.60) b1 34 105 + 9.38 3.29 + 0.34 (90 – 121) (2.38 – 3.90) c1 34 105 + 10.09 3.31 + 0.33 (85 – 122) (2.60 – 3.84) statistical analysis: groups p value a vs b1 0.000 *** 0.000*** a vs c1 0.000 *** 0.000*** b1 vs c1 0.747 ns 0.893ns group a = healthy subjects for baseline and control. group b = hemolytic anemic patients with g6pd deficiency (control) nonsupplemented group. group c = hemolytic anemic patients with g6pd deficiency (study groupl) supplemented group. b1 and c1 = on day 1; b2 and c2 = on day 60 values in parentheses indicate ranges table-ii mean (±sd) osmotic fragility of rbc in different study groups (n=102) groups n starting completing point (%) point (%) a 34 0.48 + 0.03 0.31 + 0.04 (0.45 – 0.55) (0.25 – 0.35) b1 34 0.6 + 0.04 0.42 + 0.032 (0.5 – 0.65) (0.35 – 0.45) b2 34 0.6 + 0.04 0.41 + 0.03 (0.5 – 0.65) (0.35 – 0.45) c1 34 0.59 + 0.04 0.42 + 0.028 (0.5 – 0.65) (0.35 – 0.45) c2 34 0.5 + 0.04 0.32 + 0.04 (0.4 – 0.55) (0.25 – 0.35) statistical analysis: groups p value a vs b1 0.000 *** 0.000*** a vs c1 0.000 *** 0.000*** a vs b2 0.000 *** 0.000*** a vs c2 0.245 ns 0.295 ns b1 vs c1 0.314 ns 0.546 ns b2 vs c2 0.000 *** 0.000*** b1 vs b2 0.374 ns 0.711 ns c1 vs c2 0.000 *** 0.000*** group a = healthy subjects for baseline and control. group b = hemolytic anemic patients with g6pd deficiency (control) nonsupplemented group. group c = hemolytic anemic patients with g6pd deficiency (study group) supplemented group. b1 and c1 = on day 1. b2 and c2 = on day 60. values in parentheses indicate ranges. bsmmu j vol. 1, issue. 1, july 2008 8 14 table-iii mean (+ sd) mcv, mch and mchc in different study groups (n = 102). groups n mcv (fl) mch (pg) mchc (g/dl) a 34 91 + 6.65 31 + 1.53 34 + 2.13 (73 – 105) (26 – 34) (28.5 – 40) b1 34 85 + 10.78 27 + 2.94 32 + 2.1 (65 – 104) (22 – 33) (26 – 33) b2 34 85 + 9.37 27+ 2.72 32 + 2.24 (67 – 100) (22 – 31) (26 – 35) c1 34 85 + 9.01 28 + 2.83 32 + 1.87 (65 – 101) (22 – 34) (28 – 33) c2 34 90 + 6.64 30 + 2.42 33.5 + 0.76 (77– 104) (26 – 35) (32.5 – 36) statistical analysis: groups p value a vs b1 0.025 * 0.000 *** 0.010* a vs c1 0.015 * 0.000 *** 0.018* a vs b2 0.019 * 0.000 *** 0.000*** a vs c2 0.967 ns 0.851 ns 0.773ns b1 vs c1 0.895 ns 0.773 ns 0.842 ns b2 vs c2 0.012 * 0.000*** 0.000 *** b1 vs b2 0.615 ns 0.397ns 0.136 ns c1 vs c2 0.002 ** 0.000 *** 0.002 ** group a = healthy subjects for baseline and control. group b = hemolytic anemic patients with g6pd deficiency (control) nonsupplemented group. group c = hemolytic anemic patients with g6pd deficiency (study group) supplemented group. b1 and c1 = on day 1; b2 and c2 = on day 60 values in parentheses indicate ranges. discussion: the present study revealed that patients with g6pd deficiency have significantly higher osmotic fragility of rbc along with significantly lower values of red cell indices like mcv, mch, mchc in comparison to those of healthy control. these findings are in consistent with those of some other researchers of different countries1416. on the contrary, no remarkable change in osmotic fragility of rbc and red cell indices were reported.15,23 . again, in this study after 60 days supplementation of vitamin e osmotic fragility in g6pd deficient patients was significantly decreased and it was almost close to those of healthy control. similar observations were also reported24. red cell indices ( mcv, mch, mchc) were significantly increased and moved towards normal value in the present series of patients. this finding is similar to those of some other researchers 11,13. on the other hand, no remarkable changes in these values were observed in other studies 25, which might be due to short duration and low dose of vitamin e supplementation in their studies. in g6pd deficiency oxidation of polyunsaturated fatty acid on the rbc membrane may increase its susceptibility to hemolysis25. in addition, abnormal degradation of hemoglobin, disordered cellular metabolism may also be responsible for early destruction of rbc in g6pd deficient patients11. therefore, early destruction of rbc is the consequence of higher osmotic fragility of rbc in oxidative stress26,27. in addition, decreased level of mcv, mch, mchc in hemolytic anemia with g6pd deficiency is a consequence of excessive hemolysis, more marked under oxidative stress 27,28 . therefore, increased osmotic fragility of rbc in g6pd deficiency indicates the presence of membrane defect in the present series of patients. moreover, decreased mcv, mch and mchc might be due to nutritional deficiency resulting from increased nutritional demand imposed by fragile rbc in this type of patients. vitamin e acts as an anti-oxidant by scavenging free radicals, thus prevents premature destruction of rbc19,25. therefore, supplementation of vitamin e restores osmotic fragility of rbc and thus increases rbc survival9,24. however, following vitamin e supplementation decreased osmotic fragility of rbc and shifting of mcv, mch and mchc towards normal in the patients of present study are suggestive of protective role of vitamin e supplementation in this group of patients. therefore, this study concludes that increase in osmotic fragility and decrease in red cell indices may occur in g6pd deficiency and vitamin e supplementation helps to return these values towards normal. determination of vitamin e level, red cell half-life and long time supplementation of vitamin e with larger sample size may be helpful to draw any definite conclusion. acknowledgement: this work was supported by department of physiology bsmmu, dhaka. effects of oral supplementation of vitamin e on fragility of rbc in hemolytic anemic patients nayma sultana et al 9 15 references: 1. beutler e. glucose-6-phosphate dehydrogenase deficiency. blood 1994; 84: 3613-3636. 2. galiano s, gaetani gf, barabino a. favism in the african type of glucose-6-phosphate dehydrogenase deficiency (a-). b m j 1990; 300: 236-240. 3. luzzatto l, mehta a, meloni t. hemoglobinuria and haptoglobin in g6pd deficiency. br j haematol 1995 ; 91: 511-512. 4. gostman i, muszkat m. glucose-6-phosphate dehydrogenase deficiency is associated with increased initial clinical severity of acute viral hepatitis. j gastroenterol hepatol 2001; 16(1): 12391243. 5. corash l, spielberg s, bartsocas c, boxer l, steinherz r, sheetz m, schlessleman j, schulman jd. reduced chronic hemolysis during high-dose vitamin e administration in mediterranean-type glucose-6-phosphate dehydrogenase deficiency. n eng j med 1980; 303: 416-420. 6. hafez m, amar es, zedan m, hammad h, sorour ah, desouky sa, gami, n. improved erythrocyte survival with combined vitamin e and selenium therapy in children with glucose-6phosphate dehydrogenase deficiency and mild chronic hemolysis. j pediatr1986; 108: 558-561. 7. chen bh, tsai jl, tsai ly, chao mc. comparison of serum copper, magnesium, zinc and calcium levels between g6pd deficient and normal chinese adult. kaohsiung j med sci 1999; 15: 646-650. 8. chan ac, chow ck, chiu d. interaction of antioxidant and their implication in genetic anemia. proc soc exp biol med 1999; 222(3): 274-282. 9. hasanato rmw. zinc and antioxidant vitamin deficiency in patients with severe sickle cell anemia. ann saudi med 2006; 26 (1): 17-21. 10. ono k. effects of large dose vitamin e supplementation on anemia in hemodialysis patients. nephron 1985; 40(4): 440-445. 11. jaja si, aigbe pe, gbenebipse s, temiyp eo. changes in erythrocytes following supplementation with alpha-tocopherol in children suffering from sickle cell anemia. niger postgrad med j 2005; 12(2): 110-114. 12. sarikcioglu s b, oner g, tercan e. antioxidant effect of egb 761 on hydrogen peroxide-induced lipoperoxidation of g6pd deficient erythrocytes. phytother res 2004a;18(10): 837-840. 13. usberti m, gerardi gm, micheli a m, piola t, bufano g, gaggia p, movilli e, cancarini gc, miarinis, sd, d’avolio g, broccoli r, manganoni a, albertini a, lorenzo dd. effects of a vitamin e-bonded membrane and of glutathione on anemia and erythropoietin requirements in hemodyalysis patients. j nephrol 2002; 15: 558-564. 14. grattagliano i, russmann s, palmieri vo, juni p, portineasa p, palasciano g, lauterburg bh. low membrane protein sulfhydrils but not g6pd deficiency prediet ribavirin-induced hemolysis in hepatitis c. hepatol 2004; 39(5): 1248-1255. 15. meloni t, forteleoni g, ogana a, franca v. aspirin-induced acute hemolytic anemia in g6pd deficient children with systemic arthritis. acta haemat 1989; 81(4): 208-209. 16. ajlaan sk, al-naama lm, al-naama mm. correlation between normal glucose-6-phosphate dehydrogenase level and hematological parameters. east mediterr health j 2000; 6 (2-3): 391-395. 17. razzak m. study on some aspects of hematological indices in g6pd enzyme deficient and non-deficient hemolytic anemia. m.phil. thesis 2003; bsmmu, dhaka. 18. milne db 2001. trace elements. in: c.a. burtis and e.r. ashwood, (eds). tietz text book of clinical chemistry, 5th edition. philadelphia: wb saunders company, 2001 pp: 568-583. 19. speilberg sp, boxer la, corash lm, schulman jd. improved erythrocyte survival with high-dose vitamin e in chronic hemolyzing g6pd and glutathione synthetase deficiencies. ann intern med 1979; 90: 53-54. 20. lab care diagnostic (india) pvt.ltd. accurate glucose-6phosphate dehydrogenase. quant, mumbai.2005 21. luzzatto l, ropper d. investigation of hereditary hemolytic anemias: membrane abnormalities. in: s.j.v. dace, s.m. lewis, (eds). practical hematology. oxford: heinemann professional publishing limited, 1994 pp: 215-247. 22. dacie sjv and lewis sm. practical hematology. london: elbs. 1994. 23. mengel ac, metz e, yancy sw. anemia during acute infections. arch int med 1967; 119: 287-290. 24. kraus a, roth h p, kirchgessner m. supplementation with vitamin c, vitamin e or beta-carotene influences osmotic fragility and oxidative damage of erythrocytes of zinc-deficient rats. j nutr 1997;127: 1290-96. 25. newman jg, newman tb, bowie lj, mendelson j. an examination of the role of vitamin e in glucose-6-phosphate dehydrogenase deficiency. clin biochem 1979; 12(5): 149-151. 26. zinkham hw, lenhard er. metabolic abnormalities of erythrocyte from patient with congenital nonspherocytic hemolytic anemia. j pediatr 1959;80: 319-336. 27. rubins j, young el. hereditary spherocytosis. jama 1977; 237: 797-798. 28. may j, mayer cg, grofterlinder l, ademowo og, mockenhaupt fp, olumese pe, falusi ag, luzzalto l, bienzle u. red cell glucose-6-phosphate dehydrogenase status and pyruvate kinase activity in a nigerian population. trop med int health 2000; 5(2): 119-123. bsmmu j vol. 1, issue. 1, july 2008 10 for mail.pmd 70 editorial bangabandhu sheikh mujib medical university (bsmmu) is pleased to present the first issue of the bsmmu journal. though some of the departments of the university have their own journal but bsmmu centrally does not have any journal since it’s establishment in 1998. a few months ago, a task group was formed to evaluate the possibility of starting a journal of the university. this group determined that a journal in medical science in its broadest interpretation, including all branches of medical science should be published at an earliest time. on october 2008 the editor-in-chief was selected and an editorial and advisory board was appointed to get the new journal to be started. they formulated the mission statement of the journal as we enter the new millennium and prepare to celebrate the ten years of our beloved university, we are happy to announce the arrival of our journal of bsmmu. i want to open this first issue of the journal of bsmmu thanking everybody who contribute by writing and editorial staff of this journal whose sincere and hardworking has made it reality. those of us not dealing with publishing may not perceive the enormous pressure on any scientific journal, and particularly new ones. thus we like to express our gratitude to all who helped in publishing this journal and we are looking forward to many more since they are the ones that keep the ship afloat, just like the contributors that trust the success of the journal and its crew. the primary objective of all scientific journals is dissemination of scientific knowledge. scientific publications stimulate thinking and research. it acts as repository and provides permanent record of facts. medical publications of research journals likewise play a vital role in dissemination of new data. launching scientific research oriented journal is certainly an uphill task. the number of students has increased steadily over the years. as a result, teacher’s have found it increasingly difficult to maintain the same high standards and excellence of academic and clinical teaching that has indeed been traditional and characteristic of our university. remaining busy with students and patients care perhaps we have ignored the need for a journal of the university. editorial : our first issue at present atleast 150 students in different discipline complete their m.phil, md and ms degree each year. as a part of the course they have to perform a thesis work. an estimated 200 original article should come out of these thesis. if we make it mandatory for publishing one article of the thesis in university journal, university will need atleast five regular journal to accommodate these articles. i don’t find any reason why bsmmu shouldn’t have more than one journal. i would like to remind you that this journal is meant to be your space: submit original article, case report, letter to editor and review article. in terms of style: “as far as possible our idea is that every article should be comprehensible to all readers, interesting to most readers, and actually useful to at least some readers”. it is a pleasure to acknowledge the help and encouragement from many sources and in particular from the personnel at administration of the university who have gone well beyond the terms of their contract in getting the journal started. the editorial board recognize the all full fledge help of the vice chancellor professor pran gopal datta for publishing the journal. each of you also have a vital role to play in the further development of the journal by publicizing it among your friends and colleagues, submitting manuscripts for consideration to be published and finally by telling us how the journal can be improved. to sum up our experience from few weeks of working with and for the journal, let us share some of our ideas with you. we started with an impressive list of engaged colleagues that contributed to the starting phase of the journal. due to time commitments, shift of interest, etc., we felt the need to alter the composition of the members in both the editorial board and the group of editors. professor noorzahan begum editor-in-chief 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 vol. 2 no. 2, 2009 for serial.pmd introduction: the inherited diseases of haemoglobin are the most common single gene disorders. with global improvement in childhood diseases thalassaemia will become a major health issue in millennium. the beta – thalassaemia is the most common type of thalassaemia because they are so common, occur widely in a broad belt ranging from mediterranean and parts of north and west africa through the middle east, bangladesh, india, sri lanka, thailand and other countries of south east asia1. the hereditary disorders of haemoglobin are classified into two broad groups, the thalassaemias and haemoglobinopathies. the haemoglobinopathies are characterized by the production of structurally defective haemoglobin due to abnormalities in the formation of the globin moiety of the molecule. the thalassaemias are characterized by a reduced rate of production of normal haemoglobin due to absent or decreased synthesis of one or more types of normal globin polypeptide chains2. among more than 300 structural variants, hb e is the second most prevalent haemoglobin disorder in the world. haemoglobin e/beta thalassaemiaa study in bsmmu md abdul aziz1, masuda begum2, md. sirajul islam3, naima islam4, md jalilur rahman5, amin lutful kabir1 1assistant professor, 2associate professor, 5professor, chairman, department of haematology, bsmmu, 3assistant professor department of haematology, dhaka medical college,4assistant professor department of haematology, national institute of cancer hospital, mohakhali,dhaka. abstract background: thalassaemias and haemoglobinopathies have been found sporadically in every ethnic group and geographic region, they occur with particularly high frequency from the shores of the mediterranean and africa through the middle east, the indian subcontinent, burma and southeast asia. objective: the study was designed to find out the incidence of hbe/beta thalassaemia in bsmmu. method: a total of 700 patients suspected to have been suffering from haemolytic anaemia were included in the study. patients having evidence of haemolysis in peripheral blood film were selected for reticulocyte count and haemoglobin electrophoresis in cellulose acetate membrane at ph 8.6. result: the study group of 700 patients underwent hb-electrophoresis of which only 52 (7.4%) cases were diagnosed as hbe/beta thalassaemia. out of 52 cases, 34 (65.4%) patients were found symptomatic and the remaining 18 (34.6%) patients were asymptomatic. out of 34 symptomatic cases of hbe/beta thalassaemia, only 14 cases needed blood transfusion. among the 14 patients, only 8 patients needed more than 10 units of transfusion and 6 patients needed frequent transfusion that is two units of blood in every month. conclusion: it is clearly evident from the present and other studied so far carried out in this indian subcontinent and south-east asia that hereditary haemolytic anaemia due to globin chain defects are quite common in this region, especially in bangladesh and are responsible for considerable morbidity and mortality. key words: thalassaemia; haemoglobinopathies; hbe/beta thalassemia. [bsmmu j 2009; 2(2): 78-80] address for correspondence: dr md. abdul aziz, assistant professor, department of haematology, bsmmu, shahabag, dhaka, email: aziz fcps@yahoo.com haemoglobin e is quite common in bangladesh and has a worldwide carrier of 53 millions1. these may occur due to continued migration of population from one area to another. the carrier of beta-thalassaemia trait is reported to be more than 100 millions world wide3. in bangladesh inherited haemoglobin disorders is quite common but no definitive data regarding incidence of hbe/ beta thalassaemia. the aim of the study is to find out the incidence of hbe/beta thalassaemia in bsmmu. methods: this study was carried out in the department of haematology, bsmmu from january 2002 to december 2002. a total of 700 patients of both sex, suspected to have been suffering from haemolytic anaemia were included in the study. patients under 16 years of age, and who were taking hydroxyurea and cytarabine were excluded from the study. two ml venous blood was taken from each patient under aseptic precautions and collected into edta bottles for the estimation of haemoglobin concentration, complete blood count with red cell morphology in peripheral blood film stained by leishman’s stain. patients with evidence of haemolytic feature in blood film were selected for . reticulocytes count and haemoglobin electrophoresis in cellulose acetate membrane at ph 8.6. 52 patients diagnosed as hbe/beta thalassaemia, were selected for the study population. they were thoroughly interviewed regarding the age at presentation, family history, presenting symptoms with duration of illness and blood transfusion requirement. statistical analysis was done using the spss 11.5. results were tested for level of significant using non-parametric chi-square (c2) test. ‘p’ value of < 0.05 was considered as to be statistically significant at the level of 95% ci. results: among the 700 cases only 52 cases (7.4%) were diagnosed as hbe/beta thalassaemia. the mean ± sd with range of age of the study subjects was 24.8 ± 6.1 with 16-48 yrs. out of 52 patients 28 were male (53.8%) and 24 female (46.2%) with a male: female ratio 1.17:1 as shown in table i. table i sex distribution of the hbe/beta thalassaemia subjects (n=52) sex frequency percent ratio male 28 53.8 male: female1.17:1 female 24 46.2 total 52 100.0 34 (65.4%) patients were symptomatic and the rest (34.6%) asymptomatic with statistical significance ( p = 0.027) . the symptomatic patients presented with different symptoms as shown in tableii. table ii distribution of patients by clinical presentation of hbe/beta thalassaemia subjects (n=52) clinical no. of percentage p-value presentation patients asymptomatic 18 34.6 0.027* symptomatic 34 65.4 weakness 30 88.2 pallor 22 64.7 palpitation 14 41.2 jaundice 11 32.4 abdominal lump 06 17.4 * =p<0.05 on the basis of haemoglobin level 9 patients (17.3%) had severe anaemia (hb <6gm/dl), 24 (46.2%) moderate anaemia (hb 6-10 gm/dl) and 19 (36.5%) mild anaemia (hb >10gm/ dl) with statistical significance ( p = 0.035) as shown in table iii. table iii distribution of patients by severity of anaemia of hbe/ beta thalassaemia (n=52) group no. of percentage p(hb: gmldl) patients value severe(<6) 09 17.3 0.035 moderately severe (6-10) 24 46.2 mild(>10) 19 36.5 of the symptomatic cases, 13 patients (38.2%) needed red cell transfusion (transfusion dependant) and 21 (61.8%) did not ( transfusion independent) without statistical significance ( p = 0.17)as shown in table iv. table iv distribution of patients by transfusion dependence of hbe/beta thalassaemia(n=34) blood no. of percentage ptransfusion needed patients value yes 13 38.2 0.17 no 21 61.8 discussion: the incidence of hereditary haemolytic anaemia in bangladesh is not known. however, the data regarding the incidence of hereditary haemolytic anaemia in some of our neighbouring countries is available. in india, the highest incidence of hbe trait has been reported from west bengal (3.9%), and it is also prevalent in assam and tripura states4, 5. hbe/beta-thalassaemia is the commonest of the thalassaemia syndrome in myanmar7. bangladesh is in geographical continuity with west bengal, assam, tripura states of india and with myanmar. the population in west bengal shares the common ethnic ancestry with the people of our country. out of 700 patients taken initially in this study, only 52 cases of hbe/beta-thalassaemia were found which constitutes 7.4%; and the rest 648 cases (92.6%) including betathalassaemia trait, hbe disease, hbe trait and also normal persons were not included in this study. this figure bsmmu j vol. 2, issue 2, july 2009 79 slightly differs from another study6 where the frequency of hbe/ beta-thalassaemia was 12.1%. this difference between the two studies may be due to exclusion of pediatric populations in the present study. examination of haemoglobin level in hereditary haemoglobin disorders is a very good indicator of measurement of severity of the disease. other important parameters for determining the severity of the disease are the severity of sign and symptoms of anaemia. in this present study among the 52 patients only 34 patients were symptomatic and 18 patients asymptomatic. among all, 9 patients (17.3%) were severely anaemic, 24 (46.2%) patients moderately anaemic and the rest 19 (36.5%) were only mildly anaemic (hb>10g/dl). these findings are similar to the findings in united kingdom1. exactly the same types of findings were noted by aung – thang – batu et al7. they also concluded that hbe/beta-thalassaemia is the commonest of the thalassaemia syndromes presenting with symptoms of anaemia in myanmar. another parameter of measurement of severity of the disease is transfusion dependency and frequency of transfusion. prawse wasi and his co-workers have systematically investigated the determinants for different degrees of severity of anaemia in this group of patients. they concluded that concomitant inheritance of an alphathalassaemia 1 gene leading to elevated hbf level responsible for the severity of anaemia8,9. conclusion: it is clearly evident from the present and other studied so far carried out in this indian subcontinent and south-east asia that hereditary haemolytic anaemia due to globin chain defects are quite common in this region, especially in bangladesh and are responsible for considerable morbidity and significant mortality. these are the diseases mainly of paediatric groups, adolescents and young adults. both genders are equally affected. haemoglobinopathies, particularly hbe and beta-thalassaemia are prevalent in this country. when hbe co-exists with beta-thalassaemia in the same individual, severe anaemia is manifested. the large numbers of asymptomatic patients is also hidden among the apparent normal population and are the real threat to our future generation because of the possibility of homozygous or double heterozygous inheritance or silent spread of traits through marriage. references: 1 . weatherall dj. hemoglobin and inherited disorders of globin synthesis. in a.v. hoffbrand, lewis ms, tuddenham, editors. postgraduate haematology 5 th ed. oxford: butterworth henimann 2005; p85 –103. 2 . firkin f, chesterman c, penington d, rush b. de gruchy,s clinical haematology in medical practice, 5th edition, 1989, 7: 137 – 171. 3 . bessmann jd, fein stein di. quantitative anisocytosis as a discriminant between iron deficiency and thalassaemia. blood 1979. 53: 288. 4 . gupta sc, methrota tn, methrota vg. haemoglobin ethalassaemia in uttar pradesh. indian j of medical res 1970; 58: 857 – 862. 5 . mitra ss, kambo bs. frequency of febrile illness in hbethalassaemia patient. . indian j of medical res 1984; 79: 779 – 82. 6 . haque ms, alam ma, khan wa, amin sk, banu b, hossain et al. thalassaemia situation in dhaka shishu hospital. ds (child) hj 1999; 15: 30 – 36. 7 . michael ej beard, thomas f, necheles and donald m. allen. intensive transfusion therapy in thalassaemia major. paediatrics 1967; 40: 911-915 8 . higgs. dr, vickers.m.a, wilkie ao, pretorious im, jarman ap and weatherall dj. a review of molecular genetics of the human αglobin gene cluster. blood, 1989; 73: 1081-1104. 9 . was p, poortrakul p, fucharoen s, winichagoon p, wilairant p, proomboon a. thalassaemia in south – east asia; determination of different degree of severity of anaemia in thalassaemia. ann ny acad sci 1985; 445: 119. haemoglobin e/beta thalassaemiaa study in bsmmu md abdul aziz et al 80 vol. 2 no. 2, 2009 for serial.pmd introduction: christmas disease (hemophilia b, factor ix hemophilia) is a rare bleeding disorder due to deficiency of coagulation factor ix 1. most commonly factor ix is quantitatively reduced, but in one-third of cases an abnormally functioning molecule is immunologically present. factor ix deficiency is one–seventh as common as factor viii deficiency hemophilia but is otherwise clinically and genetically identical. factor ix deficiency or dysfunction occurs in 1 in 100,000 male births2. accurate laboratory diagnosis is critical, since it is indistinguishable clinically from factor viii deficiency (hemophilia a) but requires different treatment. case report: a 25 years old college student hailing from mymenshing got himself admitted in bsmmu hospital on 2nd february, 2009 with complaints of pain and restricted movement of left hip joint for 10 days, recurrent swelling and pain in multiple joint for last 20 years and prolonged bleeding following minor trauma since childhood. on examination patient is mildly anaemic, non icteric, pulse92/min, bp110/70 mm of hg, no edema or lymphadenopathy. on examination of musculoskeletal system, there was wasting of thigh and calf muscles, tone was normal, power was 4/5, movement was reduced in both knee & elbow joints, as well as left hip joint. nervous system and other system examination reveled nothing abnormal. christmas disease (hemophilia –b) – a case report md. rafiqul alam1, mohammad saiful habib2, mohammad arifur rahman2, md. mizanur rahman khan2, m a jalil chowdhury 3, taimur a k mahmud3 1assistant professor, 2 medical officer,3professor, department of medicine, bangabandhu sheikh mujib medical university, shahbag, dhaka-1000, bangladesh abstract: we report a 25 years old man developed haemarthrosis of left hip joint with a history of recurrent swelling and pain in multiple joints and prolonged bleeding following minor trauma since childhood. subsequent investigations revealed christmas disease (haemophilia b). hemophilia b is an x-linked bleeding disorder. this case emphasises the importance of considering a diagnosis of haemophilia in a man with unexplained bleeding, even in the absence of a positive family history. [bsmmu j 2009; 2(2): 90-91] address of correspondence: dr. md. rafiqul alam, assistant professor, department of medicine, room no: 632, blockc, bsmmu, email: taimur@bsmmu.org investigation findings were hb-15gm/dl, esr-20mm in 1st hour, platelet count-330000/cmm, pbfnormal, bt2.30 sec, ct6.00 sec, pt14.5 sec (inr-1.2), aptt82.8 sec, plasma factor viii activity – 121% and plasma factor ix activity – 3.9%. considering all features he was diagnosed as a case of christmas disease with haemarthrosis of left hip joint and was treated with fresh frozen plasma only. discussion: christmas diseases is an x-linked recessive disorder. only males are affected 3. all daughters of diseased are obligate carriers and sisters have a 50% chance of being a carrier. if a carrier has a son, he has a 50% chance of having christmas disease, and a daughter has a 50% chance of being a carrier .female carriers of christmas disease may suffer due to lyonisation. here there is a low level of factor ix coagulant activity (normal50-150%) 4. most common site of bleeding are joints (knee, ankles, elbows), muscles and from gastrointestinal tract. patients with severe disease bleed spontaneously. a severely affected, may have one or two bleeds each week. recurrent bleeding into joints lead to synovial hypertrophy, destruction of the cartilage and secondary osteoarthrosis. muscle haematoma (calf and psoas muscles) are also characteristic of this disease. untreated haematomas causes subsequent contraction and shortening. intracranial hemorrhage also occur which is often fatal. in christmas disease aptt is prolonged. prothrombin time, bleeding time, fibrinogen level and vwf are normal. factor viii activity is normal but factor ix activity is reduced5. christmas disease is managed with factor ix concentrates. 80 units/ kg is necessary to achieve a 100% level. half-life of factor ix is 18 hours. during major surgery 80 units/kg (6000 u) initially followed by 40 units/kg (3000 u) every . 18 hours. factor ix concentrates can be used prophylactically twice weekly6. ddavp is not useful in this disorder. patient should be cautioned to avoid aspirin. all patients should be registered at comprehensive care centers (ccc) for medical, social and psychological supports. references: 1 . bolton-maggs ph, pasi kj. haemophilias a and b. lancet 2003; 361(9371): 1801-1809. 2 . mannucci pm, duga s, peyvandi f. recessively inherited coagulation disorders. blood 2004; 104(5):1243-1252. 3 . murphy mf, pamphilon dh. practical transfusion medicine. oxford: blackwell science; 2001. 4 . provan d, gribben j (2000) molecular haematology. oxford : blackwell science. 5 . beutler e, lichtman ma. williams hematology, 6th ed new york: mc graw-hill; 2001. 6 . mannucci pm. treatment of von willebrand’s disease. n engl j med 2004; 351(7):683-694. bsmmu j vol. 2, issue 2, july 2009 91 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 vol. 2 no. 1, 2009 correct.pmd 8 disclosure of contribution of authors corresponding author:....................................................................................................................................................... as principal investigator, dr. .................................................................................................................. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. study concept & design: .........................................................., ................................................................. acquisition of data: ..................................................................., ............................................................... analysis and interpretation of data:..........................................,.................................................................. drafting of the manuscript:........................................................, ................................................................ critical revision of the manuscript for important intellectual content:........................................................ statistical analysis:....................................................................., ................................................................ obtained funding:........................................................................................................................................ administrative, technical,or material support:............................................................................................. supervision:................................................................................................................................................. title page of article the title of the article:....................................................................................................................................................... ........................................................................................................................................................................................... 1. authors’ names and institutional affiliations: ......................1, ....................2, ...................3, ..................4, ..................5 1. ....................................................................................medical college, dhaka 2. professor & chairman of the department of. .............................................................................................., bangabandhu sheikh mujib medical university (bsmmu), bangladesh 3. associate professor, department of. ........................................................................................................... bangabandhu sheikh mujib medical university (bsmmu), bangladesh 4. assistant professor, department of. ..........................................................................................................., bangabandhu sheikh mujib medical university (bsmmu), bangladesh 5. assistant professor, department of. ............................................................................................................, bangabandhu sheikh mujib medical university (bsmmu), bangladesh 2. the name of the department(s) and institution(s) to which the work should be attributed: department of ...............................................................bangabandhu sheikh mujib medical university (bsmmu), bangladesh 3. disclaimers any: yes, subject to non profit purpose 4. corresponding author: the name:........................................................................................................................................................................... mailing address: ............................................................................................................................................................. telephone:.......................................................................................................................................................................... e-mail address: ................................................................................................................................................................ 5. the name and address of the author to whom requests for reprints should be addressed:......................................... mailing address: ............................................................................................................................................................... 7. source(s) of support in the form of grants, equipment, drugs, or all of these [self finance] 8. a short running head:....................................................................................................................................................... 9. word counts of abstract : [239] 10. the number of tables : [2] 11. the number of figures : [2] for mail.pmd 32 introduction: tumor, malignancy, radionecrosis, cystic lesion, trauma, infection or congenital anomalies may be reasons for mandibular defects. among them the benign lesion affect most commonly.1-3 the management of mandibular continuity defect has changed in the last decade. the most frequently used technique for reconstruction of extended defect is the transfer of vascularized osseous free graft. the fibula, scapula, rib and the illiac crest are the preferred donor-sites for reconstruction.4, 5 it is essential to establish bone viability after revascularization of the graft . lack of vitality as a result of vascular occlusion either arterial or venous can result in graft necrosis, bone resorption and poor healing. reconstruction of mandibular defect by free re-vascularized fibula graft: a case report quazi billur rahman1, mahmudur rahman1, showkat mamun1, munjur iqbal2, binay kumar das3 1associate professor, department of oral & maxillofacial surgery, faculty of dentistry, bsmmu, 2 mph (student), nipsom, 3medical officer, department of oral & maxillofacial surgery, dhaka dental college abstract: background: in maxillofacial surgery tumor ablation often causes continuity defect of mandible which results anatomical and functional morbidity of the patient. the reconstruction of the mandibular defect is mandatory to restore the oral function and speech. various methods of immediate reconstruction are implemented by different authors time to time including autogenous non vascularized bone graft, allogenic bone graft , auto frozen mandible or reconstruction plates and others. each has its own advantages and disadvantages including donor site morbidity, failure and others. the purpose of the present case report is to establish micorvascular free fiblula is as a better option to other methods in immediate reconstruction of mandibular continuity defect. objective: anatomical, functional and esthetic rehabilitation of patients after mandibular resection method: revascularization of free fibula graft by microvascular anastomosis of paroneal artery with facial artery at the segmental defect site of mandible. result: remarkable contour, cosmesis and early functional rehabilatation of the patient. conclusion: microvascular reconstruction with fibula is the better option for defect correction and early rehabilitation in patients with mandibular continuity defect. key word: mandible, defect, reconstruction, microvascular technique, fibula graft [bsmmu j 2008; 1(1): 35-38] address of correspondence to: dr. quazi billur rahman, department of oral & maxillofacial surgery, faculty of dentistry, bangabandhu sheikh mujib medical university (bsmmu), dhaka incidence of ameloblastoma in mandible is one of the most common causes of mandibular defect. goal of the surgery, include resection of mandible and immediate reconstruction to maintain the functionspeech, mastication & deglutation, facial contour and oral competence.6 however, the best option to reconstruct mandibular continuity defect has not yet been satisfactorily resolved and represents a challenge for oral and maxillofacial surgeons. case history: a 18 years old bangladeshi woman came to the opd of oral & maxillofacial surgery dept. of bangabandhu sheikh mujib medical university with 2 years history of slowly growing lesion at the left side of the lower face. fig.1: preoperative view of the patient with close (a) & open (b) (c) mouth. 33 the lesion was non-tender and there was no regional lymphadenopathy with no motor or sensory functional deficit. she was otherwise fit and was not medically compromised. on examination the size of the lesion was 7.5cm x 4cm, extended from left lateral incisor to 3rd molar of mandible. cortical expansion was marked on the buccal side but lingual expansion of the cortex was minimal. there was no intra oral or extra oral persistent sinus or discharge. the remainder of the oral cavity was unremarkable. two teams were involved in the surgery. one team extirpated the tumor and the other team simultenously harvested the fibula. a left submandibular approach was used to expose the lesion. subperiosteal dissection was carried out to expose the tumor and it was resected with 1 cm healthy bone on each side. the facial artery and the vein were secured with vascular clips for future vascular anastomosis. on the donor site the other team simultaneously exposed the fibula utilizing lateral approach. a line was drawn from the fibular head to the lateral malleolus indicating the submascular and subcutenous course of fibula. two markings were made on the line. first was 7 cm distal from the fibular head which indicate approximate insertion of peroneal vessels within the intermascular septum. second marking was 14 cm distal from the fibular head indicating the approximate location of nutrient vessels. a curvilinear incision is then make along the lateral border of the peroneal muscles. the posterior intermuscular septum was identified separating the peroneal muscle from soleus muscle. the septum is separated from its attachments to the fibula along its posterior border. dissection next proceeds anteriorly toward the anterior intermuscular septum which seperates the peroneal muscle from the extensor muscle. extraperiosteal dissection proceeds and about 1cm cuff of flexor hallucis muscle with associated peroneal vessels was left attached to the fibula. the paroneal vessels were identified at the distal osteotomy site and were ligated. the paroneal vessel was identified to their origin from posterior tibial artery. the first osteotomy cut was done 4cm distal to the nutrient vessel by gigli saw with 1 cm excess periosteum. the second osteotomy cut was done 4cm proximal to the nutrient vessels with 1cm excess periosteum also. the osseous tissue attached only by its fig.-2: preoperative orthopantamogram orthopantamograph revealed a multilocular radiolucent lesion involving the body of the madible from left lateral incisor to third molar. clinically, radiologically and histologically it was diagnosed as a case of ameloblastoma. methods: she underwent surgery as a case of ameloblastoma with the treatment plan of a wide excision of the lesion followed by immediate reconstruction with revascularized fibula graft for the first time in our country. fig.3: a) excised tumour b) harvesting of fibula with patent paroneal vessels c) adapted fibula graft with plates bsmmu j vol. 1, issue. 1, july 2008 36 34 with good wound healing. she had an excellent recovery both functionally & aesthetically. she was under in regular follow up in the department of oral and maxillofacial surgery. she was released after 10 days of surgery and cameto the first follow-up after one month of surgery. in first follow-up she was apparently better with no donor and recipient site complication both clinically and radiologically. in second follow-up three months (fig.4) after the surgery the oral opening, closing and mastication was adequate. in radiological observation the graft was in proper position and significant amount of callous was formed with no complication with the donor site. the final follow-up (fig.5) was given after one year which reveled excellent functional and cosmetic result. radiologically the bony union was completed and no resorbtion of the graft was observed except two miniplates on either side but the medullary cavity of the graft was the isolating criteria from the graft and mandible.. fig.5: follow up after one year a) closed mouth b) open mouth c) opg after one year. fig.-4: postoperative front view after 3 months. vascular pedicle was observed for balanced perfusion after deflating the torniquet. then the proximal peroneal vessel was ligated and cut. the graft was then trimmed and adapted to the defect as per size and shape and stabilized by miniplate with screws. the end to end anastomosis was done in between paroneal and facial artery with 9/0 prolene under aided vision of loop in a convetional way. the clamps were released and patency of the anastomosed vessel was observed for a little period. then the wound was closed in layers with water tight seal in the oral cavity. follow up: she received broad spectrum antibiotic, analgesics for 10 days and antiseptic mouth wash for 14 days following surgery. the entire post operative period was uneventful discussion mandible plays an important role in airway protection, support for the tongue, muscles of the floor of the mouth, lower jaw dentition, articulation, deglutition, speech, respiration and facial aesthesis. vascularised osseous free graft are used to good advantage in maxillofacial surgery for the reconstruction of mandibular defect following mandibular resection. the goal of the reconstruction areestablishment of mandibular continuity with acceptable cosmetic result, establishment of osseous alveolar base for further dental rehabilitation, correction of soft tissue defect.7 the surgeon has to balance his procedure to achieve best cosmetic appearance with reliable function. in order to achieve it one must restore bony continuity, facial contour, tongue mobility and speech. for restoration reconstruction of mandibular defect by free re-vascularized fibula graft: a case report quazi billur rahman et al 37 35 of the mandibular defect the use of autogenous bone is the preferred option. the other options are solely alloplastic materials or alloplast & bone graft together. alloplastic materials are in the form of stainless steel plates (alloy of iron, chromium, nickel) or vittalium (alloy of chromium, cobalt, molybdenum) 8. facial deformity, poor aesthetics, orocutaneous fistula was noted after mandibular reconstruction by other convetional methods due to lack of vascularity.10 but in our case these were not observed. the fibula provides the longest segment of bone with 2030 cm available for harvest. in addition the segmental blood supply of the bone permits multiple osteotomy. the bone is also adequate width & height to allow placement of osseointigrated dental implants. donor site morbidity with this graft is minimal unless the distal osteotomy site is within 6cm of the ankle. in addition the location of the graft will allow simultenous harvest by a second team at the time of tumor resection.5,9 in our case 9 cm of fibular graft was used to reconstruct the mandible. there is a risk of peroneal nerve injury with resultant foot drop or weakness in planter flexion of the great toe which can be avoided with meticulous dissection. advances in anastomotic technique, monitoring devices will add to its success.in the follow up period, orthopantamogram should be done routinely to assess bone resorption and every time compared with the immediate postoperative radiograph. references: 1. keszler a, guliemotti mb, dominguez f. oral pathology in children: frequency, distribution, and clinical significance. acta odontal latinoam. 1990; 5: 39-48. 2. cordeiro pg. disa jj. hidalgo da. hu oy. reconstruction of the mandible with osseous free flaps a 10-year experience with 10 consecutive patients. plast reconstr surg 1999; 104: 1314-20. 3. foster rd. anthony jp. sharma a, pogrel ma. vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction an outcome analysis of primary bony union and endosseous implant success. head neck 1999; 21: 66-71. 4. urken ml. weinberg h, vickery c. oromandibular reconstruction using microvascular composite free flaps. arch. otolaryngol head neck surg. 1991; 117: 733-44. 5. genden e, haughey bh: mandibular reconstruction by vascularized free tissue transfer. am j otolaryngol. 1996; 17: 21927. 6. ritvik p. mehta and daniel g. deschler. mandibular reconstruction in 2004: an analysis of different techniques. current opinion in otolaryngology & head and neck surgery 2004; 12: 288-293. 7. urken ml. buchbinder d. chapter 86. in: cummings cc editor. oromandibular reconstruction in otolaryngology-head and neck surgery. st louis: mosby year book. 1998 p.1654-68. 8. koch wm, yoo gh. goodstein ml. advantages of mandibular reconstruction with the titanium hollow screw osseountegrating. reconstruction plate (thorp). laryngoscope 1994; 104: 545-52. 9. horiuchi k, hattori a, inada i. mandibular reconstruction using the double barrel fibular graft. microsurgery 1995; 16: 450-54. 10. hidalgo da, pusic al. free-flap mandibular reconstruction: a 10-year follow-up study. plast reconstr surg 2002; 110: 438-39 bsmmu j vol. 1, issue. 1, july 2008 38 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 vol. 2 no. 1, 2009 correct.pmd 34 introduction: in maxillofacial surgery, there is always a need to fill the bony defects following surgery. so bone grafts are often necessary to provide support, fill voids, and enhance biologic repair of skeletal defects. in the orofacial region various types of bone grafts have been used that includesautografts, allografts, xenografts and alloplastic materials. radicular cyst is the most common type of inflammatory odontogenic cysts of the jaws, which comprises nearly 65%-70% of all jaw cysts1 and dentigerous cyst is the most common type of developmental odontogenic cyst of the jaw which is nearly 15%-18% of all jaw cysts. following enucleation of a cyst defects smaller than 2 cm in diameter can be closed primarily and normally fill up with blood clot. but in case of large defect clot breakdown and infection are more likely to occur in a large haematoma. so it is considered as good technique to obliterate the dead space of a sizable defect by packing the cavity with bone or a bone substitute. in the large bone grafts in jaw cystshydroxyapatite & allogenic bone – a comparative study showkat mamun, mahmuda akhter, motiur rahman molla department of oral and maxillofacial surgery, faculty of dentistry, bangabandhu sheikh mujib medical university. abstract: background: auto bone is the gold standard in bone grafting. however, the morbidity and additional surgical time associated with its collection, as well as the limited supply, have stimulated the search for substitutes. allograft is more limited than autograft because it yields more variable clinical results. composite synthetic grafts offer an alternative because hydroxyapatite is chemically identical to the inorganic matrix of living bones and it can be processed synthetically. the intent was to evaluate these two graft materials for clinical use and to provide an insight on the different grafting strategies to enhance bone formation. objective: to find out the bone healing process and the prognostic value for the patient using hydroxyapatite alloplastic material and allogenic bone graft. method: total 28 patients were included in the study after the clinical and radiological evaluation where 14 cases were treated with allogenic-bone graft and rest 14 cases were treated with hydroxyapatite alloplastic material after enucleation of the cystic lesion in random manner. the integration of hydroxyapatite and allogenic bone was assessed with postoperative lesion diameter, trabecular pattern, histopathological and scintigraphic examination of the successful graft cases. statistical analysis was carried out by ‘unpaired t test’ and ‘chi square’ test. result: the radiological, histopathological and scintigraphical outcome of the patients treated with hydroxyaptite granule bone graft were clinically and statistically superior in comparison with those who were treated with allogenic bone graft. conclusion: this safe and osteoconductive hydroxyapatite appears suitable for filling bone defects and bone cavities, showing less resorption and a rapid osseous integration. key word: hydroxyapatite, allogenic bone, scintigraphy, radiology, histopathology. [bsmmu j 2009; 2(1): 25-30] address for correspondence: dr. showkat mamun, department of oral and maxillofacial surgery, faculty of dentistry, bangabandhu sheikh mujib medical university. email: mamunshowkat@gmail.com surgical cavity, residual contour defects due to collapse of soft tissue into the cavity can be eliminated and the repair process appears clinically and roentgenographically to proceed more rapidly than after simple surgical excision 2. although autogenous bone is the gold standard that all alternatives must meet or exceed, autograft has limitations, including donor site morbidity, inadequate amount, and inappropriate form 3-5. these limitations have prompted increasing interest in alternative to bone grafts. consequently, significant efforts are being made to develop ideal bone graft substitutes. 6 synthetic ceramics are readily available and are without infectious or immunogenic potential. they reduce patient morbidity significantly by reducing the need for a second operative site. calcium phosphates (cap) account for most ceramic-based bone graft substitutes currently available. hydroxyapatite (ha) is the most used polycrystalline calcium phosphate ceramic mineral as an artificial bone graft substitute. it is biocompatible, highly resistant to stress forces, nontoxic and noncarcinogenic. it has marked osteoconductive and osteoinductive properties that lead to the regeneration of lamellar bone within 4 to 10 months 35 of implantation. this characteristic is exploited in many surgical areas (orthopedics, maxillofacial surgery, dentistry, plastic surgery and neurosurgery). it also has been used to coat other materials to increase their stability and osteointegration. it has been used to reconstruct defects of the jaw and other facial bones, to obliterate mastoidectomy cavities and to reconstruct the ossicular chain and wall of the outer ear canal. other uses of hydroxyapatite range from augmenting atrophic alveolar ridges to repairing long-bone defects, ununited fractures, middle ear prostheses, spinal fusions, and cranioplasties. unfortunately, the major drawbacks to the use of cap ceramics are their adverse mechanical properties. they are brittle, have low impact resistance, and have low tensile strength; consequently, they fail when used in a structural capacity. the lack of viscous flow is a serious limitation for cpcs. despite this problem, some researchers tried injecting cpcs in paste form. the most notable among such reports is that of constantz et al 7. its tendency for granular migration and incomplete resorption has become a long-term problem 8. allogenic bone is another attractive source of bone grafting material next to auto bone. allogeneic bone, with variable biologic properties, is available in many preparations: frozen, freeze-dried, irradiated, or demineralized. transplantation of allogenic bone as a method of treatment as various disorders of skeleton was started late decade of 19th century and 1st decade of 20th century. freeze-dried bone allograft was first introduced by united state navy tissue bank in 1951 9. though allografts are attractive sources, there are several problems encountered in using them, including resorbtion, relative risk of disease transmission, immunogenicity, loss of biologic and mechanical properties secondary to its processing, and non-availability world-wide due to financial and religious concerns. bone trabeculae are composed of thin radiopaque plates and rods. to evaluate the trabecular pattern in a specific area it is necessary to compare with the surrounding bony trabeculae and some time with previous radiograph. scintigraphic images are obtained utilizing the intravenous administration of a radiopharmaceutical, particularly technetium-99m labeled diphosphonates. in an in vitro binding assay, the competitive adsorption of technetium99m labeled diphosphonates to pure hydroxyapatite is forty times greater than to pure organic bone matrix. thus, its uptake correlates well with the rate of mineralization 10. harbert 11, mentioned that bone scintigraphy provides a means of predicting graft failure before radiographic or clinical changes become apparent and, thus, helping to avoid a loss of surrounding bone from graft necrosis or infection. thus the study is designed to evaluate the integration of ha and allogenic bone as bone graft by assessment of postoperative lesion diameter, trabecular pattern, histopathological evaluation and scintigraphic assessment of the graft to its future use with maxillofacial reconstruction. method: it was a prospective study conducted in the department of oral and maxillofacial surgery, bangabandhu sheikh mujib medical university between the period of july 2006 to june 2008. 28 patients were included in the study with inclusion criteria of non infected cystic type of lesion (radicular and dentigerous cyst), lesion size between 2 cm to 7 cm in diameter. patients with any systemic bone disease or diabetes, tuberculosis, rheumatic heart diseases and renal failure, psychologically abnormal patients or patients who had taken radiotherapy in the orofacial region were excluded. total 28 patients were included in the study after the clinical and radiological evaluation. among them 14 cases were treated with allogenic-bone graft and rest of the 14 cases were treated hydroxyapatite alloplastic material after enucleation of the cystic lesion in random manner. after all preoperative investigations and radiological examination in selected cases were operated following standard surgical procedure meticulously in sterile environment under local anesthesia and sedation. enucleation of cyst was done with removal of all granulation tissue. after enucleation of cyst bony cavity was irrigated with diluted povidone iodine for the purpose of debridment. granules of hydroxyapatite or allobone was placed on the surgical defect and wetted with patient blood or saline solution followed by primary closure of the wound. (fig-1, fig-2) the wound was checked on the following day and radiograph was done three days after operation. sutures were removed on seventh post operative day. assessment: observation of the diameter of the lesion – the final initial radiological diameter was recorded at the 3rd post operative day to get the exact extension of the lesion because the surgical procedures have changed the preoperative lesion diameter. bsmmu j vol. 2, issue 1, january 2009 26 36 then the initial diameter of the lesion was measured and follow-up was done for each patient with occlusal view/ opg or intraoral periapical view with the same magnification, exposure time , kv, in the same x ray machine with the same operator so that measurement of lesion diameter have the accurate result measured with a mm scale. each opg was done by cranex base x (finland) panoramic dental x-ray machine with ma set to 10 and kv set to 75 for each patient. each occlusal view was done with ma set to 100, kv set to 50 and exposure time set to 0.10 sec from exactly the same distance and angulation for each of the patient. for each periapical view jyf -10 (china) xray machine is used with ma was set to 10 , kv set to 55 and exposure time was set to 0.80 sec again with maintaining the same distance and angulation. the margin of the successful bone grafts showed less sharpness than the immediate post operative margin in each case after one month. observation of trabecular pattern of woven bonetrabecular pattern of woven bone with each patient was evaluated visually by comparing the x-ray of the same patient from two different focuses using a standard scale with image processing software in collaboration with the department of radiology and imaging, bangabandhu sheikh mujib medical university. . the first focus is from the healthy portion of bone with normal trabecular pattern and the second focus is from the intervented cystic defect with the graft which has lost the normal trabecular pattern or from the region of interest of the same patient assuming 100% trabecular pattern is present in the first focus and comparing it with the region of interest. histopathological examination was done after six month of operation. few patients were randomly selected from each group both hydroxyapatite and allobone. tissue specimen was taken from all these cases after reflecting the mucoperiosteum at the previous lesion area to find out the presence or absence of cementing line, osteoblast, woven bone, fibrous and chronic inflammatory cell to assess the quality of the graft material in the healed lesion. this was done in the department of pathology, bsmmu with their detailed pathological report. scintigram was done after six month of operation. few patients were randomly selected from both hydroxyapatite and allobone graft group. three phase scan was done with technetium99m labeled diphosphonates for each patient to access the viability of bone graft or areas of increased bone metabolism are evidence of good viability and appear as areas of increased radiotracer uptake, namely “hot spots”. diminished or absent uptake are called “cold spots”. data analysis: in the study different variables were analyzed in all subjects including: age, sex, site of lesion, size of lesion, cortical bone status, oral hygiene radiological findings (diameter of radiolucency and trabecular pattern after 1, 3 and 6 months), histologic examination of the cystic cavity margin after 6 months of operation, scintigraphic findings (evaluation of tracer uptake after 6 months of operation) all the data sheet of history and x-ray were collected and analyzed scientifically and computer based statistical analysis using spss software was carried out with appropriate techniques and systems. results were presented as a detailed pathology report that includes highresolution digital photomicrographs with image processing software. data were analyzed statistically by ‘unpaired t test’ and ‘ chi square’ test. results: the mean diameter of lesion was 3.3±0.98 cm in group a (with hydroxyapatite bone graft) and 3.9±1.40 cm in group b (with allogenic bone graft) during preoperative period. after 1 month the mean diameter declined and found 2.67±0.89 cm in group a and 2.80±0.99 cm in group b. after 3 months the mean diameter further reduced and found 1.92±0.63 cm in group a and 2.00±0.77 cm in group b. finally after 6 months the mean diameter was 0.96±0.23 cm in group a and 1.25±0.45 cm in group b. the difference was statistically significant (p<0.05) after 6 months but after 1 month and 3 months the difference was not statistically significant (p>0.05) (table-i). fig.-1: surgical procedure of hydroxyapatite bone graft in a cystic cavity. bone grafts in jaw cystshydroxyapatite & allogenic bone – a comparative study showkat mamun et al 27 37 fig.-2: surgical procedure of allogenic bone graft in a cystic cavity. fig. -3: radicular cyst, treated with hydroxyapatite bone graft. significant radiological improvement was observed. fig.-4: dentigerous cyst treated with freeze dried allogenic bone graft. significant radiological improvement was not observed. preoperative view post operative view after 6 months fig.5: patient treated with hydroxyapatite bone graft. under microscope with high magnification shows osteoblastic activity and cementing line which indicates woven bone formation. fig. -6: patient treated with allogenic bone graft. under microscope with high magnification shows fibrous tissue deposition and chronic inflammatory cell which indicates no new bone formation. fig.-7: patient treated with freeze dried allogenic bone graft. radionuclide bone scanning shows less tracer uptake which indicates average osteoblastic activity. bsmmu j vol. 2, issue 1, january 2009 28 38 table-i mean lesion diameter of the patients between two groups group-a group-b (n=14) (n=14) p value mean ±sd mean ±sd preoperative 3.30 ±0.98 3.90 ±1.40 0.167 ns after 1 month 2.67 ±0.89 2.80 ±0.99 0.725 ns after 3 months 1.92 ±0.63 2.00 ±0.77 0.770 ns after 6 months 0.96 ±0.23 1.25 ±0.45 0.039s group-a: with hydroxyapatite bone graft group-b: with allogenic bone graft ns= not significant, s= significant, p value reached from unpaired t-test table-ii distribution of the patients by management type and incidence of infection. post operative group-a group-b (n=14) (n=14) p value infection number % number % infection occur 0 0.0 5 35.7 no infection 14 100.0 9 64.3 0.020s total 14 100 14 100 group-a: with hydroxyapatite bone graft group-b: with allogenic bone graft s= significant p value reached from chi square test fig.-8: patient treated with hydroxyapatite bone graft. radionuclide bone scanning shows increased tracer uptake which indicates good osteoblastic activity. discussion: it was found that in reducing the diameter of lesion with hydroxyapatite bone grafts were both clinically and radiologically better than allogenic bone graft (fig-3). it was supported by zuev et al12. this observation was concluded by them that the patients with hydroxapatite bone graft showed better radiological outcome than their allogenic counterparts. they also revealed the outcomes of two groups, poorly defined in the initial few weeks but in the later period like three months it was significant, this result is very close to schwartz et al. 13 patients with hydroxapatite bone graft showed superior trabecular pattern than the allogenic counterparts (fig-4). the difference of trabecular pattern between the two groups started to amplify in the post operative period. the difference was almost persistent throughout the period of 6 months, with gradual increasing tendency. histopathological slide was prepared from randomly selected cases of both study and control group from same site and procedure after six months of operation. according to the histopathological findings the neo-osteogenetic process was better in the hydroxyapatite group (fig. 5, fig. 6). microscopic findings revealed that the graft was seated in the duel process of osteoclastic and osteoblastic activities with the ingrowths of capillaries. there was marked cementing line which indicates deposition of woven bone; on the other hand there was less definite histological feature of active bone formation rather fibrous deposition showed in allogenic bone group. moreover the infiltration of chronic inflammatory cell was evident in allo group. radionuclide bone scanning was done from randomly selected cases of both groups. more increased tracer uptake was seen in the operation site of hydroxyapatite group than that of in the allo group (fig. 7, fig. 8) which is also supported by the finding of jun14. more tracer uptake of radioactive iodine indicates good osteoblastic activity. on the other hand slight tracer uptake indicates average or poor osteoblastic activity. post operative infection was not found in hydroxyapatite bone graft group and 5(35.7%) in allogenic bone graft group and the difference was statistically significant (p<0.05). infection occurred in 1(20.0%) in maxilla and 4(80.0%) in mandible (table-ii). the infection was remarkably less in the hydroxyapatite group because of its fine granular structure which contributed to very reduced anatomical dead space than that of the allografts which had larger particles which bsmmu j vol. 2, issue 1, january 2009 29 39 contributed to infection. after placement of hydroxyapatite as a graft it solidifies and work as single unit of osseointegrated structure that also contributes to less infection than the allo group which is supported by the findings of zasacki 10. infection occurred usually with in the one week after operation and presented by the features of localized swelling and exudation which leads to exposure of grafted materials. this condition was then treated by removal of the graft material and curettage of necrosed tissue and use of proper antibiotics. the allograft group was more infected than the hydroxyapatite graft group may be due to loss of biological properties secondary to its processing which was supported by friedlander 6. other reasons for this inconsistency include variable donor age with material from older donors being less osteoinductive, how carefully the material is processed, the level of residual calcium and the final particle size of the prepared graft reported by schwartz and coworkers14. conclusion: the radiological, histopathological and scintigraphical outcome of the patients treated with hydroxyaptite granule bone graft were clinically and statistically better in comparison with those treated with allogenic bone graft. none of the patient of the hydroxyapatite group was infected. this safe and osteoconductive ha appears suitable for filling bone defects and bone cavities, showing less resorption and a rapid osseous integration. references: 1. stockdale cr, chandler np. the nature of the periapical lesion: a review of 1108 cases. j dent 1988;16: 123-129 2. marble h.b. jr, captain dc usn. homografts of freeze –dried bone in cystic defects of the jaws. federal dental services 1968; 26(1): 118. 3. banwart jc, asher ma, hassanein rs. iliac crest bone graft harvest donor site morbidity: a statistical evaluation. spine 1995; 20: 1055-60. 4. cowley sp, anderson ld. hernias through donor sites for iliacbone grafts. j bone joint surg am 1983; 65: 1023-25. 5. summers bn, eisenstein sm. donor site pain from the ilium: a complication of lumbar spine fusion. j bone joint surg br 1989; 71: 677-80. 6. freidlaender ge. immune responses to osteochondral allografts current knowledge and future directions. clin orthop 1983; 174: 58-68. 7. constanz br, ison ic, fulmer mt. skeletal rapair by in situ formation of the mineral phase of bone science 1995; 267: 179699. 8. rosen hm, mcfarland mm. the biologic behaviour of hydroxyapatite implanted into the maxillofacial skeleton. plast reconstr surg 1990; 85: 718–23 9. zasacki w. the efficacy of application of lyophilized, radiation sterilized bone graft in orthropaedic surgery. clin orthro relt res 1991; 272: 82-87. 10. francis md, horn pa, tofe aj. controversial mechanism of technetium-99m deposition on bone. j nucl med 1981; 22: 72. 11. harbert jc. the musculoeskeletal system in: harbert jc, eckelman wc, newmann rd (eds). nuclear medicine: diagnosis and therapy. new york: thieme 1996; 801-63 12. zuev vp, dmitrieva la, pankratov as. the comparative characteristics of stimulators of reparative osteogenesis in the treatment of periodontal diseases [article in russian]’, stomatologiia (mosk) 1996; 75(5): 31-34. 13. schwartz z. ability of commercial demineralized freezedried bone allograft to induce new bone formation. j periodontol 1996; 67( 9): 92530. 14. jun manabe pasteurized autologous bone graft in surgery for bone and soft tissue sarcoma j clin orthop 2004; 419: 258. bsmmu j vol. 2, issue 1, january 2009 30 vol. 2 no. 1, 2009 correct.pmd 23 introduction: although hepatitis c virus (hcv) related chronic liver disease is common in our clinical practice, unfortunately there is lack of representative population study in bangladesh regarding the prevalence of the virus. this present study is among the handful where the seroprevalence of hcv in our population has been studied. except for the work by a japanese group, that reported 5% prevalence of hcv in bangladesh1, others reported extremely low prevalence of hcv in bangladesh2. this gives the impression that the impact of hcv in bangladesh is negligible. on the other hand a british study has shown that 45.3% and 56% of british-bangladeshi patients with chronic liver diseases and hepatocellular carcinoma respectively have been infected with hcv3. there are also published data from bangladesh identifying hcv to be the etiological agent in 24.1% of patients with chronic liver diseases in bangladesh4. all these diversifying reportings make it essential to revisit the prevalence of hcv in this country, especially among the apparently healthy individuals. epidemiology of hepatitis c virus in bangladeshi general population mamun-al-mahtab1, salimur rahman2, fazal karim3, graham foster4, susannah solaiman5 1assistant professor, 2professor, department of hepatology, bangabandhu sheikh mujib medical university, dhaka, bangladesh, 3consultant medicine, dhaka mohanagar hospital, 4professor, 5research fellow, digestive diseases research centre, bart’s and the london queen mary’s school of medicine and dentistry, london, uk. abstract background: hepatitis c virus is encountered sporadically in bangladesh. it results in a wide range liver diseases, with asymptomatic acute hepatitis rarely at one end to hcc at the other end of the spectrum. methods: 1018 individuals of different age groups and sex with varied religious, educational and social backgrounds were tested for anti-hcv by elisa. before testing, blood samples were preserved at -20°c. the study was conducted in a semi-urban location on the outskirts of dhaka. results: 0.88% tested positive for anti hcv. none of them tested positive for hbsag. there was a male predominance and those who tested positive were mostly between 17 and 50 years of age. major risk factors for exposure to hbv appeared to be injudicious use of injectable medications, treatment by unqualified, traditional practitioners, mass-vaccination against cholera and smallpox, barbers and body piercing. conclusion: hcv remains an important cause of morbidity and mortality in bangladesh. key words: hcv, prevalence, general population, bangladesh. [bsmmu j 2009; 2(1): 14-17] correspondence to : dr. mamun-al-mahtab, assistant professor, department of hepatology, bangabandhu sheikh mujib medical university, shahbag, dhaka-1000, bangladesh, email: shwapnil@agni.com materials and methods the study was conducted in the savar area on the outskirts of dhaka in may 2007. the area has a large industrial base. the leading export processing zone of the country is also situated here. people from all over the country stay and work in different industrial and other installations in this area. moreover, due to its proximity and excellent communication with dhaka city, many people from different parts of the country reside here and commute to dhaka daily for work and business. it was therefore assumed that the study population was representative of the bangladeshi population. before the samples were collected, several meetings were held with local political, social, religious and business leaders in order to ensure community participation and full cooperation. we arranged mass propaganda to encourage people to participate in the study. during jumma prayers, imams (i.e. muslim priests) urged the common people to participate in the study. extensive broadcasting was done and posters and banners were erected in key locations. 20 graduate physicians were employed to obtain consent from the participants and fill in a pre-designed questionnaire for each individual. 10 phlebotomists collected blood, maintaining all aseptic precautions, while a group of 5 laboratory technicians were involved in 24 sample preservation. large number of volunteers were employed to ensure smooth execution of the exercise. the sample size was 1018. prior, informed, written consent was obtained from every participant. a questionnaire was filled in for each individual. all samples were stored at -20°c and tested for anti-hcv by elisa (abbott, usa). results in all, 1018 individuals were included in the study. participants of either sex, between 1 to over 50 years of age, with different religious, social, professional and educational backgrounds, donated blood voluntarily for the study (table i). the completed questionnaire contained detailed information on relevant demographic data and risks of possible exposure to hcv (table ii). table i demographic characteristics of study population age distribution age in yrs. nos. % 0-16 0 0 17-50 9 100 50+ 0 0 sex distribution sex nos. % male 6 66.66 female 3 33.34 religion of study population religion nos. % muslim 6 66.66 hindu 3 33.34 christian 0 0 education level level nos. % no education 0 0 primary 3 33.34 high school 6 66.66 college 0 0 university 0 0 table-ii risk factors for hcv positivity risk factor nos. % yes no. yes no. blood transfusion 0 9 0 100 dental procedure 0 9 0 100 h/o jaundice 0 9 0 100 < 6 months > 6 months sutures 0 9 0 100 surgery 0 9 0 100 i/v infusion 0 9 0 100 abscess drainage 0 9 0 100 urinary catheterization 0 9 0 100 blood donation 0 9 0 100 endoscopy 0 9 0 100 injection/epi immunization 0 9 100 0 vaccination (smallpox, cholera) 6 0 0 100 treatment from quack 6 3 66.66 33.34 shaving/haircut in barber shop 3 6 33.34 66.66 tooth brush sharing 0 9 0 100 body piercing 3 6 33.34 66.66 tattooing 0 9 0 100 i/v drug abuse 0 9 0 100 alcohol 0 9 0 100 multiple sexual partners 0 9 0 100 family h/o hepatitis 3 6 33.34 66.66 family h/o liver disease 3 6 33.34 66.66 acupuncture 0 9 0 100 circumcision 3 6 33.34 66.66 by surgeon 0 0 by hajam 3 100 pregnancy 3 0 100 0 1 no. 0 0 2 nos. 2 66.67 3 nos. 1 33.33 4 nos. 0 0 5 nos. 0 0 6 nos. 0 0 abortions 1 2 33.33 66.67 1 no. 1 100 2 nos. 0 0 miscarriages 1 no. 2 nos. forceps/ventouse deliveries 1 no. 2 nos. deliveries by caesarean section 1 2 33.33 66.67 1 no. 1 100 2 nos. 0 0 breast feeding 2 1 66.67 33.33 hcv in bangladesh mamun-al-mahtab et al 15 25 of the participants 0.88% (9/1018) tested positive for antihcv. all who tested positive were in the age group of 1750 years. males predominated over females. 66% (6/9) positive subjects were males and the remaining 33 % (3/ 9) were females. 66% (6/9) were muslims and rest 33% (3/9) hindus. 66% (6/9) had high school education, while 33% (3/9) received primary education. none had any history of jaundice. the risk factors for exposure to hcv are listed in table ii. none had co-infection with hepatitis b virus (hbv). discussion the study reveals that in our population the highest prevalence of hcv is among young adults and middleaged individuals with a male predominance. this favours horizontal transmission as the principal mode of transmission of the virus, as we could not identify anyone positive for anti-hcv in the 0-5 years age group. the most important risk factor for exposure to hcv as revealed by this study is treatment by ‘quacks’ (i.e. nonqualified traditional medical practitioners) including circumcision by ‘hajams’ (i.e. traditional rural practitioners skilled in carrying out circumcision) and delivery by ‘dhais’ (i.e. traditional birth attendants) who are unaware of the consequences of unhygienic and unsterile interventions. since these people still provide the backbone of primary health care in our rural areas, educating them properly regarding sterilization and hygiene is important. injectable drug abuse however is not a major problem in our country, possibly due to religious beliefs and social norms. while, as predicted, barbers appear to be responsible to some extent for transmission of the virus, surprisingly dental procedures, contrary to our usual belief, do not appear to pose a significant threat. the traditional practice of ear and nose piercing by our women is also an important route of hcv transmission and thus extra care is warranted before one goes for a hair cut or pierces a tissue. at one time, before the discovery of the mode of transmission of hcv, mass-vaccinations against cholera and smallpox were carried out in bangladesh and involved repeated use of the same needle. although it resulted in the eradication of smallpox and in control of cholera, it seems to be taking its toll now, as a significant proportion of the study population who tested positive had a history of such vaccination. this is similar to the resultant rise in hcv infection in egypt following mass-vaccination against schistosomiasis. the prevalence of hcv as revealed by this study is similar to that reported in the indian sub-continent where the figure varies between 1%-5%5. the indian sub-continent is in the intermediate prevalence zone of the virus. the lowest prevalence of hcv is seen in uk and scandinavia where it is 0.01%-0.1% and is slightly higher in usa (0.2%) and western europe (0.5%). higher percentages have been reported from eastern europe, middle east and the mediterranean5. hcv poses a huge burden on the health of bangladeshis, being a leading cause of all forms of chronic liver diseases next only to hbv6, 7. this is similar to the experience in india8, 9, pakistan10 and nepal11, 12. hcv also ranks to be a leading cause of hcc in bangladesh13 as well as in the region including india8 and pakistan14. historically, bangladesh has been a hyper-endemic area for viral hepatitis. patients with hepatitis are encountered in bangladesh round the year and epidemics due to hepatitis a and e viruses (hav and hev) have broken out on several occasions in the last century. this study, which was mainly aimed to find out the prevalence of hcv in bangladesh may not be a truly representative one in regard to sample size, but at the same time it is one of the earliest as well as best designed epidemiologic studies in bangladesh for hcv and shows that a small percentage of our population are infected with the virus. our data contradicts the 0% or 5% prevalence of hcv among our population as reported by earlier researchers4, 1. however our observation is in line with our clinical experience in bangladesh, where hbv infection and hbv related chronic liver disease patients are encountered much more commonly than those caused by hcv. the reason for reportings of such low or high prevalences of hcv by our predecessors is not exactly known, but sample size, sensitivity of anti-hcv elisa kit used etc. may have influenced their data. although the prevalence of hcv is not high in our population, given that we have a population of more than 140 million in bangladesh, the total number of hcv infected individuals in this country is understandably very high. this deserves special attention as voluntary blood donation is getting popular in bangladesh, but there is still serious concern regarding screening of donated blood for hcv, especially in the non-government setting. studies carried out among combined injectable drug users and heroin smokers in bangladesh report of hcv prevalence in them to be as low as 7% to as high as 77% in different parts of the country15. since these people are the principal source of commercial blood donation in the country, antihcv screening must therefore be strictly implemented, if we are to avoid a deadly epidemic that may not be too far away. the other issue that needs to be addressed to prevent bsmmu j vol. 2, issue 1, january 2009 16 26 spread of hcv is to ensure screening patients for the virus before any surgical or dental procedure, a practice that is equally important, but almost not existent in bangladesh. acknowledgement we are grateful to square pharmaceuticals ltd., dhaka, bangladesh, for an un-restricted grant for this study. references 1. akbar smf, hossain m, hossain mf, sarker s, hossain sas, tanimoto k, masumoto t, michitaka k, horiike, onji m. seroepidemiology of hepatitis viruses of chronic liver diseases in bangladesh: high prevalence of hcv among blood donors and healthy persons. hepatol research 1997; 7: 113-120. 2. khan m, yano m, hashizume k, yousuf m, tanaka e, matsumoto a, et al. comparison of seroepidemiology of hepatitis c in blood donors between bangladesh and japan. gastroenterol jpn 1993; 28(5): 28-31.. 3. zaman m. khan m, alam k, williums i. primary hepaioocellular carcinoma and viral hepatitis b and c infection in bangladeshi subjects. j trop med hyg 1995; 98: 64-68. 4. khan m, ahmed n, rabtuan s, zaki kmj, matin ma. interferon therapy in chronic viral hepatitis in bangladesh: a preliminary report. int hepatol common 1995; 3 (suppl): 104. 5. yen t, keffe eb, ahmed a. the epidemiology of hepatitis c virus infection. j clin gastroenterol 2003; 36: 47-53. 6. mahtab ma, rahman s, khan m, kamal m, karim mf, ahmed f, hussain mf, podder pk. aetiology of chronic hepatitis: experience from a tertiary centre in bangladesh. indian j gastroenterol 2007; 26 (2): 142. 7. afroz s, mahtab ma, rahman s, khan m. hepatitis b virus is the leading cause of cirrhosis of liver in bangladesh. hepatol int 2007; 1 (1): 120. 8. sarin sk, chari s, sundaram kr et. al. young vs. adult cirrhotics: a prospective comparative analysis of the clinical profile, natural course and survival. gut 1988; 29: 101-107. 9. acharya sk, panda sk, duphare h et. al. chronic hepatitis in a large indian hospital. nat med j india 1993. 6: 202-206. 10. zuberi sj. seroepidemiology of hbv/hcv in pakistan. int hepatol comm 1996; 5: 19-26. 11. shreatha sm, tsuda f, okamoto h et. al. hepatitis b virus subtypes and hepatitis c virus genotypes in patients with chronic liver disease in nepal. hepatology 1994; 19: 805-809. 12. shreatha sm. incidence of hbsag carrier rate in pregnant women in kathmandu. j inst med 1987; 71-76. 13. khan m, zaki kmj, ahmed ku. clinical profile: prognostic index in hepatocellular carcinoma. bangladesh med res council bull 1991; xvii: 49-62. 14. abdul mujeeb s, jamal q, khanani r et. al. prevalence of hepatitis b virus surface antigen and hcv antibodies in hepatocellular carcinoma cases in karachi, pakistan. trop doct 1997; 27: 45-46. 15. national hiv serological surveillance, 2006 bangladesh. national aids/std programme, directorate general of health services, ministry of health and family welfare, government of the people’s republic of bangladesh. hcv in bangladesh mamun-al-mahtab et al 17 for mail.pmd 9 introduction disseminated intravascular coagulation (dic) is a syndrome characterized by inappropriate and excessive activation of haemostatic system. dic is usually initiated by exposure of blood to tissue factor, presents on the cell surface that surround blood vessels. brain and placenta are especially rich in tissue factor1. dic results from trauma, obstetric accident, diffuse vascular injury, increased endothelial permeability or circulating cancer cells resulting pathologic activation of the extrinsic and/ or intrinsic pathway of coagulation or impairment of clot inhibiting influences2,3. in subacute or chronic dic, there is slow activation of haemostatic system, with spontaneous bruising rather than major clinical bleeding episodes. rarely, a chronic compensated form of dic can continue for many years, usually associated with intrauterine infection, internal malignancy or vascular malformations. the principles of management of dic are control of haemorrhage, elimination of precipitating factors and specific coagulation factor replacement therapy. here we are going to present such a rare case of chronic dic. case report a 35-years-old woman was admitted in medicine department of bangabandhu sheikh mujib medical university (bsmmu) on 11th march 2004 with the complaints of echymoses of variable sizes and color for 5 months. she complained of epistaxis, gum bleeding, haematuria, melaena and menorrhagia. she gave history of prolonged bleeding after minor trauma and delayed chronic disseminated intravascular coagulation: a case report md. abul kalam azad1, m abdul kader2, m abdul jalil chowdhury3, tofayel ahmed3 1associate professor of medicine, bangabandhu sheikh mujib medical university, 2assistant professor of medicine, bangabandhu sheikh mujib medical university, 3professor of medicine, bangabandhu sheikh mujib medical university. abstract: in health there is a balance between the coagulation and anti-coagulation systems, but in disseminated intravascular coagulation (dic) the coagulation mechanism is activated inappropriately and in a diffuse way. this may lead to thrombosis, but more often haemorrhage occurs when the clotting factors are exhausted. dic may present as acute, subacute, and rarely chronic form. here we present a case of chronic dic following pelvic inflammatory disease (pid) as a consequence of repeated menstruation regulation (mr). we treated her with fresh frozen plasma, fresh blood, doxycycline with significant clinical improvement. [bsmmu j 2008; 1(1): 33-34] wound healing for the said duration. she stated about repeated oral ulcers without any fever, arthralgia/ arthritis, bone pain, photosensitivity or malar rash. she had no history of such previous bleeding episode either in her or in her family members. she was mother of two healthy children. she gave a history of mr seven months back, but she remained amenorrhic for more than two months. her urinary hcg test was positive at that time, and sonogrphic examination revealed retained product of conception and dilatation and curettage (d&c) was done. she had no significant drug history except oral contraceptive pill. on general examination, she was anxious, moderately anemic, with multiple non-tender, non-palpable echymoses on the extensor surface of both limbs, of variable sizes and colours, which didn’t blanch on pressure. her peripheral blood film was suggestive of anemia of chronic disorder (haemoglobulin 7.8gm/dl) with high esr (98mm in 1st hour) and normal platelet count (155,000/ul). sonogaphic examination of pelvic organ revealed that uterus was mildly enlarged. clotting time was prolonged i.e. 18 minutes, with normal bleeding time. her prothrombin time was 48 second (control: 13 sec), activated partial thromboplastin time (aptt) was 128 seconds (normal 30-40 seconds), thrombin time was 22 seconds (control: 16 sec) and factor viii activity was 25% (normal range 60-150%). her ana was positive in low titer (two fold rise) and anti-dsdna and anti-sm test were negative. initially she was suspected of having vasculitic disorders and treated with steroid, but there was no clinical improvement. her plasma fibrinogen was 2.37g/l (normal 1.5-4.0gm/l) but fibrin degradation correspondence to : dr. md. abul kalam azad, associate professor of medicine, bangabandhu sheikh mujib medical university, dhaka, bangladesh, e-mail: azadbsmmu@yahoo.com case reports 10 product (fdp) and d-dimer (normal ‹0.2mg/dl) were 5 µgm /l and 0.5 µgm/ ml respectively, i.e., both were increased. per vaginal examination revealed that uterus was bulky with fluid collection in the pouch of douglas and diagnosed a case of chronic dic due to pelvic inflammatory disease (pid) as a consequence of retained products of conception. she was treated with cap. doxycycline (100 mg) b.d. for one month as well as with five units of fresh frozen plasma and one unit of whole fresh blood with significant clinical improvement. after a few days, her coagulation profile was repeated and was within normal limit (pt -14 seconds, aptt -38 seconds, tt -12 seconds, plasma fibrinogen 250 mg/dl, fdp-<05 µgm /ml and d-dimer-<0.5 µgm /ml). discussion: disseminated intravascular coagulation is an acute, subacute or chronic thrombohaemorrhagic disorder occurring as a complication in a variety of diseases. it is characterized by activation of the coagulation sequence that leads to the formation of microthrombi throughout the microcirculation of the body and accelerated fibrinolysis4. dic usually presents as an acute, often catastrophic, acquired haemorrhagic tendency. rarely it can also manifest as a low grade disorder with predominantly thrombotic manifestations5. chronic dic may occur due to intrauterine fetal death, giant haemangiomas (kasabach merritt syndrome) or adenocarcinoma. intrauterine infection causes endotoxins to be released into the maternal circulation and damage of the blood vessels releases thromboplastins, which causes chronic dic. other etiologic factors of chronic dic are aneurysms, vasculitis, leiomyomas, hydatidiform mole etc6. in chronic dic, intravascular coagulation and fibrinolysis don’t proceed fast enough to outstrip the rate of synthesis of clotting factors or inhibitors. this may simply reflect low grade, weak or intermittent activating stimulus, in which case dic is often mild and asymptomatic7. destruction and production of coagulation factors and platelets are balanced. the pathophysiology of such chronic, subacute or compensated dic is fundamentally the same as that in the acute case. nevertheless, the distinction is valuable because the clinical pictures and laboratory findings in the chronic form are quite variable and may be diagnostically confusing6. in chronic dic, superficial but extensive ecchymosis of extremities may develop intermittently or may persist for weeks or months. recurrent episodes of epistaxis or more serious internal mucosal bleeding may punctuate the course. dic, caused by carcinoma, may cause bleeding or recurrent deep and superficial venous thrombosis8. intrauterine fetal death may produce chronic dic, particularly if the fetus is retained for several weeks9. in chronic or subacute dic, prothrombin time, activated partial thromboplastin time and thrombin time are prolonged but platelet count may be normal or low. fibrinogen concentration may be normal or low. however, there is usually an increase in fibrin degradation product (fdp) and increased level of d-dimer5. conclusion: chronic or subacute dic is a rare, catastrophic haemorrhagic disorder or sometimes shows a thromboembolic manifestation. we diagnosed her as a case of chronic dic due to retained product of conception. but we failed to explain why her ana was increased. for this reason she should further followed up as she may develop any connective tissue disease. it is further to see whether ana disappear spontaneously. references 1. drake t, morrissey j, edgington t. selective cellular expression of tissue expression factor in humans tissues. implications for disorders of haemostasis and thrombosis. am j pathol 1989; 134: 1087-2001. 2. lijima k, fukuda c, nakamura k. measurements of tissue factor like activity in plasma of patients with dic. throb res 1991; 61:29-41. 3. cortan rs, kumar v, robbins ls. robins pathologic basis of disease. 6th ed. bangalore: w.b. saunders company; 1999. p 623-626. 4. machin js. acquired coagulation disorder. in; hoffbrand av, lewis sm, tuddenham ed, editors. postgraduate haematology. oxford: butterworth heinemann; 1999. p.640-645. 5. brozovic m. acquired disorders of blood coagulation. in: bloom al and thomas dp, editors. haemostasis and thrombosis. new york; churchill livingstone; 1981; p.640-645. 6. grosset ab, rodgers gm. acquired coagulation disorders. in: richard d, foster j, rodgers gm, editors. wintobe’s clinical haematology. baltimore: wilkin’s; 1999; p.1733-1753. 7. williams ec, mosher dh. disseminated intravascular coagulation. in: hoffmann r, shattil sj, edward jb, editors. basic principles and practice of hematology. new york: churchill livingstone; 1995; p. 1758-1766. 8. sack j, levin j, bell w. trosseau’s syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms. medicine 1977; 56: 1-8. 9. hatch rl, barke ji, barke mw. coagulopathy associated with dilatation and evacuation for intrauterine fetal death. obst and gynaecol 1985; 66: 463-478. bsmmu j vol. 1, issue. 1, july 2008 34 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access 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forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 10. early outcome of radiculopathy.ai | original | article | early outcome of radiculopathy with local application of steroid in perineural space in lumbar discectomy mohammad farid raihan, asifur rahman, abu saleh mohammad abu obaida, md shahnawaz bari, md atikur rahman, hafiz asif raihan, olinur razib, mohammad kamruzzaman bhuiyan, md jaynul islam, mirza hafizur rashid, mohammad hossain introduction lumbar discectomy is effective in improving pain, quality of life and function in patients with lumbar intervertebral disc herniation and radiculopathy.1 however, in the immediate postoperative period, many patients experience low back pain, radiculopathy, delayed rehabilitation and hospital discharge.1,2 the commonly used and well-established strategies to treat postoperative pain include analgesics, both nsaids and opioids in oral or injectable forms.3 nowadays, the application of anaesthetics in peri-neural space is becoming a new modality to reduce radicular pain. after discectomy and before the closure of the wound, a corticosteroid solution is applied around the nerve root that has been decompressed. the rationale for this is that steroid reduces local inflammation around the neural elements; this, in turn, reduces the article info abstract department of neurosurgery, bsmmu, dhaka (mfr, ar, asmao, msb, mar, or, mh); department of neurosurgery, mag osmani medical college, sylhet (har); department of physical medicine and rehabilita�on, bsmmu, dhaka(mkb); department of neurosurgery, na�onal ins�tute of neuro science & hospital, dhaka(mji, mhr) for correspondence: mohammad farid raihan email: faridraihan8@gmail.com cite this ar�cle: raihan mf, rahman a, obaida asma, bari ms, rahman ma, raihan ha, razib o, bhuiyan mk, islam mj, rashid mh, hossain m. early outcome of radiculopathy with local applica�on of steroid in perineural space in lumbar discectomy. bangabandhu sheikh mujib med univ j. 2022; 15(2): 107-110. copyright: the copyright of this ar�cle is retained by the author(s) [atribu�on cc-by 4.0] available at: www.banglajol.info a journal of bangabandhu sheikh mujib medical university, dhaka, bangladesh lumbar disc herniation resulting in compression and inflammation of nerve roots causes low back pain and radiculopathy. per-operative use of steroids may help reduce inflammatory reaction and scar formation, causing less postoperative pain. the study aimed to assess the early outcome of radiculopathy with local application of steroids in peri-neural space after lumbar discectomy. this experimental study was carried out in the department of neurosurgery of the national institute of neuroscience and hospital (nins&h), dhaka from march 2019 to august 2020. a total of 68 patients operated for prolapsed lumbar intervertebral disc (plid) at l4/l5 and /or l5/s1 levels were divided into two groups. patients who did not receive steroids (n=34) and those who received steroids (n=34) in peri-neural space were considered group a and group b, respectively. patients were examined on the 1st, 2nd and 14th postoperative days to measure the pain intensity by the visual analogue scale (vas). pre-operatively mean (standard deviation, sd) vas was 7.41 (1.28) in group a and 7.91 (0.9) in group b (p-value >.05). mean (sd) improvement of pain intensity on day 1, was 58.82 (17.55)% in group a and 70.59 (12.26)% in group b from pre-operative vas. on day 2, 71.69 (12.43)% improvement was seen in group a and 79.78 (9.74)% in group b. on day 14, 75.37 (9.96)% improvement was seen in group a and 83.46 (7.36)% in group b from pre-operative. the improvements of vas in all 1st, 2nd and 14th days were statistically significant (p-value <.05) between the two groups. local application of steroids in peri-neural space found effective in reducing early postoperative radiculopathy following lumbar discectomy. received : 12 february 2022 accepted : 22 march 2022 available online : 15 may 2022 issn: 2224-7750 (online) 2074-2908 (print) doi: h!ps://doi.org/10.3329/bsmmuj.v15i2.60864 keywords: lumbar disc hernia�on,radiculopathy, low back pain pain experienced by the patient. however, the use of intraoperative epidural corticosteroids is debatable.5-6 so, we aimed to access the early outcome of radiculopathy following lumbar discectomy, a common surgery in bangladesh with the local application of steroids in peri-neural space. methods this experimental study was carried out on 68 patients diagnosed with prolapse lumbar intervertebral disc (plid) at l4/l5 and/or l5/s1 levels in the department of neurosurgery of national institute of neuroscience and hospital (nins&h), dhaka, bangladesh from march 2019 to august 2020. ethical clearance for the study was taken from the department of neurosurgery and irb, nins&h and informed written consent was taken from each patient. pre-operative 108 bsmmu j 2022; 15(2): 107 110 distribution of the study patients by age (n=68) age (years) non-steroid steroid p value group a group b (n=34) (n=34) n % n % ≤30 6 17.4 7 20.5 31-40 14 40.9 15 44.1 41-50 9 26.4 7 20.5 51-60 5 14.6 5 14.6 mean±sd 39.59±11.17 39.74±10.43 0.912ns table-i distribution of the study patients by sex (n=68) sex non-steroid steroid p value group a group b (n=34) (n=34) n % n % male 21 61.8 21 61.8 1.000ns female 13 38.2 13 38.2 table-ii neurological examinations were done. the patients were divided equally into group a and group b, each having 34 patients based on local application of steroids in peri-neural space following discectomy. surgery was carried out without local application of steroids in group a and with the local application of steroids in group b. patients were re-examined on the 1st, 2nd and 14th post-operative days to measure the intensity of radicular pain. following meticulous haemostasis, 40 mg of methylprednisolone acetate was given around the decompressed nerve root in group b (steroid group). in group a (non-steroid group), nothing was given, and the wound was closed in a standard procedure. postoperatively, patients of both groups were assessed by vas score and recorded on the 1st, 2nd and 14th postoperative days. the pain intensity was graded from 0 (no pain) to 10 (the most severe pain). the vas scores between the groups were compared using an unpaired t-test. statistical analysis was carried out using the statistical package for social sciences (spss inc chicago, illinois, usa) version 25.0 for windows. a descriptive analysis was performed for all data. a p-value <.05 was considered statistically significant. results table-i shows the distribution of the study patients by age. it was observed that more than one-third (40.9%) of the patients belonged to age 31-40 years in group a and 15(44.1%) in group b. the mean (sd) age was 39.59 (11.17) years in group a and 39.74 (10.43) in group b (p-value >.05). table ii shows the distribution of the study patients by sex. it was observed that almost two-two-thirds (61.8%) of patients were male in both group a and group b (p-value >.05). it was observed that the mean (sd) vas was 7.41 (1.28) in group a and 7.91(0.9) in group b before the operation. on the 1st day, mean (sd) vas was 3.29 (1.4) in group a and 2.35 (0.98) in group b. similarly, on the 2nd day, mean (sd) vas was 2.26 (0.99) in group a and 1.62 (0.78) in group b. in addition, on the 14th day, mean (sd) vas was 1.97 (0.8) in group a and 1.32 figure 2: line chart showing the distribution of the study patients according to vas (0.59) in group b, which were a significant decline from pre-operative in both groups in all follow-up but more decline in group b. on the other hand, the mean percentage of vas improvement on day 1 from the preoperative period was 58.82±17.55% in group a and 70.59±12.26% in group b. the mean percentage of vas improvement on day 2 from the preoperative period was 71.69±12.43% in group a and 79.78±9.74% in group b. the mean percentage of vas improvement at day 14 from the preoperative period was 75.37±9.96 and 83.46±7.36 in group a and group b, respectively. the mean percentage of vas improvement on a postoperative day 1st, day 2nd and day 14th were statistically significant (p<0.05) in group b, which indicates that the application of steroids in peri-neural space reduced early postoperative pain following lumbar discectomy. 0 1 2 3 4 5 6 7 8 9 pre-operative day 1 day 2 day 14th m e a n vas group i group ii bsmmu j 2022; 15(2): 107 110 109 distribution of the study patients according to visual analogue scale preoperative and postoperative day 1, day 2 and day 14 (n=68) vas group a (n=34) group b (n=34) p-value mean±sd mean±sd pre-operative vas 7.41±1.28 7.91±0.9 0.067ns postoperative vas (day 1) 3.29±1.4 2.35±0.98 0.002s % of improvement from pre-operative vas 58.82±17.55 70.59±12.26 0.001s postoperative vas (day 2) 2.26±0.99 1.62±0.78 0.004s % of improvement from pre-operative vas 71.69±12.43 79.78±9.74 0.001s postoperative vas (day 14) 1.97±0.8 1.32±0.59 0.001s % of improvement from pre-operative vas 75.37±9.96 83.46±7.36 0.001s s=significant, ns=not significant, p value reached from unpaired t-test table-iii discussion the incidence of lumbosacral radiculopathy is estimated to be approximately 3–5%.6,7 the prolapsed lumbar intervertebral disc is one of people's most common vertebral column diseases leading to back pain, radicular pain, and neurological deficit due to nerve root compression.8 intraoperative epidural steroids have been used as adjuvant pain therapy in lumbar disc surgery. they reduce postoperative pain by suppressing mediators of inflammation.9 thus, the use of steroids reduces postoperative pain by minimizing the early inflammatory reaction and helps in less scar tissue formation, ultimately reducing hospital stay, back pain radicular pain and neurological deficits.8 the age and gender distribution of the present study are compatible to the other previous studies.9 in this current study, it was observed that the mean percentage of vas improvement on postoperative days 1, 2 and 14 were significantly (p<0.05) more in group b, which indicates that the application of steroids in peri-neural space reduced early postoperative radicular pain following lumbar discectomy. preoperative vas scores between the two groups were not statistically significant (p>0.05). postoperatively on day 1, vas scores were 3.29 and 2.35; on day 2, it was 2.26 and 1.62; and on day 14, is was 1.97 and 1.32 for control and steroid groups, respectively, suggesting significant relief in back pain and radiculopathy compared to preoperative status. however, there was a statistically significant difference in vas score on day 1 (p=0.002), day 2(p=.004) and day 14(p=.001) postoperatively when comparing group a and group b. the pain level can be communicated through a visual analogue scale.9 a low dose of methylprednisolone (40 mg), which was left on the decompressed nerve root, was found to be able to decrease the intensity of the immediate postoperative radicular pain and also found statistically significant in the first and second postoperative days and in the sixth to twelfth days. steroids administered epidurally in patients with disc hernia were also found to provide significant radicular pain relief postoperatively in 78% of the patients.10 studies found that epidural methylprednisolone during lumbar discectomy reduced hospital stay, recovery time, leg pain, and neurological deficits. there were no side effects of epidural methylprednisolone in the 2-year follow-up period.5 oedema and inflammation of the nerve root or dorsal root ganglions and handling of the nerve root are responsible for creating uncomfortable situations for many patients and may increase the postoperative requirement of anti-inflammatory analgesics or morphine derivatives and expose the patient to adverse effects related to these medicines.9 radicular pain following disc surgery is related to a number of factors that include the inflammatory cascade which is triggered by tissue trauma and direct manipulation of the nerve root. it is thought that using steroids reduces postoperative pain by suppressing mediators of pain and inflammation such as prostaglandins, leukotrienes, bradykinin and histamine.5 conclusion it can be concluded that the local application of steroids in peri-neural space reduces immediate postoperative pain effectively. vol. 3 no. 2, 2010.pmd editorial the anthrax outbreak anthrax is a zoonatic diseasea disease of animal transmissible secondarily to human being.. human to human transmission of anthrax is very rare because of the fact that the vegetative form of the bacteria present in the diseased man or animal can not cause the disease. the bacteria bacillus anthracis is a spore forming organism. it is the spore present in the soil is the only infective form. cutaneous anthrax is the most common form and it occurs by contact with infected animal, raw meat or by contact with animal during the process of slaughtering or during preparation of cooking of meat from infected animal. anthrax exists in animals and human beings in many countries of asia and africa including bangladesh. institute of epidemiological disease control and research (iedcr) detected 13 small scale outbreaks since 2009. the recent outbreak was first detected in the district of sirajganj in the month of august and then the disease spread to 12 other districts. it infected 607 persons so far and all of them had cutaneous anthrax. all the infected persons got cured and outbreak of anthrax has been effectively controlled by the combined effort of the iedcr, health and livestock directorate of gob. no new case has been reported since 8 october 2010. anthrax is not at all a life threatening disease. cutaneous anthrax can be effectively treated by administering simple antibiotics like ciprofloxacin or doxycyclin for 7-10 days. ingestion of meat does not usually cause anthrax. inhalation has got some historical importance. that is the reason why anthrax outbreak has caused wide scale panic among general population. consequently consumption of meat fell down remarkably. the anthrax panic dates from bio-terrorism attack in usa in 2001in which 24 people were infected by anthrax bacillus. this deadly infection was caused by exposure to bacillus anthracis in a powder that had been sent through the mail. out of them 11 suffered from inhalation anthrax and the rest had cutaneous anthrax. among the inhalation anthrax cases 5 persons died while the rest were totally cured. on april 2, 1979, there was an unusual anthrax outbreak which affected 94 people and killed at least 64 of them in the soviet city of sverdlovsk. the outbreak was caused by an accidental release of anthrax spores from a suspected soviet biological weapons facility there is no chance of inhalation anthrax in our country since this form of disease is generally caused by bioterrorism attack or rarely from industrial exposure. the recent out break of anthrax is of cutaneous variety and is treatable with simple antibiotic. the anthrax outbreak can occur at any time and is dependent on environmental and climatic factors. there is no reason to be panicking as the disease itself is not life threatening but to be aware. however, the health and animal husbandry directorate could jointly undertake an initiative for building awareness about its cause, how it spreads and its likely impact upon human health among the people at large. m. a. jalil chowdhury1, sharmin ahmed 2 1professor, 2fcps student, department of medicine, bsmmu vol. 3 no. 2, 2010.pmd introduction central nervous system (cns) tumors comprise 2% to 5% of all tumors. 80% involve the brain and 20% involve the spinal cord. brain tumors cause approximately 2% of all cancer deaths. 60% to 80% of brains tumors are primary and rest 20% to 40% are metastatic.1 tumors of the cns account for as many as 20% of all cancers of childhood and are second only to leukaemia as a cause of death from malignancy. in childhood 70% of primary brain tumors are infratenorial and involve cerebellum, midbrain, pons and medulla. 2 benign tumors of the brain tend to grow slowly and some of them may be cured by surgery with or without radiation therapy. the malignant tumors grow more rapidly and are associated with a shorter survival. some of those highly lethal tumors, such as medulloblastoma and ependymoblastoma have a tendency to disseminate throughout the cns. there are increasing data documenting a genetic basis or at least a genetic association with some brain tumours. an association of brain tumours with certain chemical/drugs, epstein-barr virus and irradiation has been reported. 3,4 in our country, there is no epidemiological and statistical data regarding various features of brain tumors. although, clinical and pathological characteristics of brain tumor naziruddin mollah1, abdul baki2, nur afzal3, akram hossen4 1resident. department of oncology, bsmmu. 2senior medical officer, birdem hospital. 3medical officer, police hospital. 4 professor, department of oncology, bsmmu abstract background: cns tumors comprise 2% to 5% of all tumors. there was no epidemiological and statistical data regarding various features of brain tumors in this country. 80% involve the brain and 20% involve the spinal cord. brain tumors cause approximately 2% of all cancer deaths. objectives: to evaluate the clinical and pathological characteristics of brain tumors. methods: this prospective study was done at oncology department and neurosurgery department of bangabandhu shiekh mujib medical university from july 2006 to june 2007. total 50 patient age 2-60 years attending the oncology department with the diagnosis of primary brain tumor were included in this study. clinical symptoms and sign in relation to brain tumor were recorded. x ray skull and ct scan reports of all cases were evaluated. to find out the histopathological pattern of the brain tumors all histopathological reports were also evaluated. results: most common symptoms of brain tumor were headache (76%), mental change (64%), vomiting (52%), visual defect (46%), difficulty in movement (42%) and convulsion (36%). astrocytoma was found in 40% patients and 30% brain tumor was associated with hydrocephalus conclusion:this study represent the brain tumor and gives some idea about the clinicopathological aspects of the disease in our country. it will help to do further studies to evaluate the clinical, epidemiological and pathological characteristics of brain tumor. [bsmmu j 2010; 3(2): 68-71] the incidence of brain tumours has not been determined in our country, overall clinical experiences indicate that its incidence is not low. this study was done to evaluate the clinical and pathological characteristics of primary brain tumors. methods: this retrospective study was done at oncology department and neurosurgery department of bangabandhu shiekh mujib medical university from july 2006 to june 2007. total 50 patients age 2-60 years attending the oncology department with diagnosis of primary brain tumor were included in this study. primary brain tumor was diagnosed by neurosurgery department of bsmmu. study procedure: all patients with primary brain tumor fulfilling inclusion criteria were included in the present study. a predesigned data collection sheet was used for each subject and informations regarding history, clinical examination and investigations were recorded. after inclusion of the cases, data were collected from surgeon’s clinical notes. history of the patients was taken in details with special emphasis given on the following points: age, sex, religion, occupation, socioeconomic condition, educational status, residence, history of radiation exposure, family history, personal history and past history of illness with a view to address for correspondence: dr. naziruddin mollah, resident. department of oncology, bsmmu, dhaka find out any relationship with the brain tumor. clinical symptoms and sign in relation to brain tumor were recorded. x ray skull and ct scan reports of all cases were evaluated. to find out the histopathological pattern of the brain tumors all histopathological reports were also evaluated. collected data was analyzed by using statistical package for social science (spss version 12.0). results: among the 50 patient 66% were male and male female ratio was 1.9:1. mean (+sd) age of the patients were 46±11 years. seventy percent patients came from rural area and 92% patients were muslim. forty eight percent patients from middle socioeconomic background and rest from higher or lower socioeconomic status. there was no difference in socioeconomic status. most common symptoms of brain tumors were headache (76%), mental change (46%), vomiting (52%), visual defect (46%), difficulty in movement (42%) and convulsion (36%). others symptoms were complete blindness (20%), dementia (14%), unconsciousness (14%), fever (06%), weight gain (06%), anorexia (04%), vertigo (04%), sensory loss (04%) and loss of libido (02%). in most of the cases more than one symptom were present (table-i). table-i distribution of patient according to presenting symptom (n=50) symptoms no. of cases percentage headache 38 76.0 vomiting 26 52.0 vertigo 02 04.0 convulsion 18 36.0 anorexia 02 04.0 fever 03 06.0 mental change 32 64.0 dementia(past/recent memory) 07 14.0 difficulty in movement 21 42.0 sensory loss 02 04.0 visual defect 23 46.0 complete blindness 10 20.0 disturbance of consciousness 03 06.0 unconsciousness 07 14.0 weight gain 03 06.0 loss of libido 01 02.0 large number of patients had signs of increased intracranial pressure (58%), focal presentation (46%), visual defects (50%), and oculomotor and abducens nerve defects (12%), other signs (less frequent) includes sensory level defects (12), facial palsy (08%), incoordination (06%), endocrine abnormalities (06%), parinaud’s syndrome (02%). in most of the cases more than one signs were present (table-ii) table-ii distribution of patient according to presenting sign (n=50) signs no. of percentage cases focal presentation related to 23 46.0 tumor location (hemiplegia, hemi paresis, monoplagia, aphasia) sensory level defect 06 12.0 increased intracranial pressure 29 58.0 (papilloedema) visual defects 25 50.0 oculomotor and abducens nerve 16 32.0 defects (squint/diplopia/pupillary abnormality) facial palsy 04 08.0 in coordination 03 06.0 endocrine abnormalities 03 06.0 (hypopituitarism/hyperpituitarism) parinaud’s syndrome 01 02.0 x ray skull was done in all patients. more than 50% of case there were no radiological findings, 32% cases showed bony lesion and 14% cases showed calcification (fig 1). ct was done in all patients and hydrocephalus was detected in 30% patients (fig 2) fig.-1: radiological finding of skull in brain tumor (n=50) bsmmu j vol. 3, issue 2, july 2010 69 histological examination was done in all patients. 40% patients had astrocytomas. pituitary tumors and meningiomas were 16% and 14% respectively. other tumor types include, craniopharyngioma (06%), pineal tumour (08%), ependymoma (04%), medulloblastma (04%), oligodendroglioma (02%), brain stem tumor (02%), thalamic tumor (02%) (table-iii). table-iii histological finding of brain tumor (n=50) type no. of cases percentage astrocytoma 20 40.0 grade-i 06 12.0 grade-ii 09 18.0 grade-iii 02 04.0 grade-iv 03 06.0 meningioma 07 14.0 pituitary tumour 08 16.0 craniopharyngioma 03 06.0 pineal tumour 04 08.0 ependymoma 02 04.0 medulloblastma 02 04.0 oligodendroglioma 01 02.0 brain stem tumour (radiologically) 01 02.0 brain tumour 01 02.0 (thalamic radiologically) discussion: the present study is a clinicopathological study of brain tumor. clinical presentation may very according the site and type of brain tumor, although there are some common symptoms, namely, headache, seizure, mental change and sensorimotor defects and any of which can eventually be found in more than 50% of the patient population. ocular change (e.g. visual defect) is associated with the tumors, like, pituitary adenoma craniopharyngioma optic nerve glioma and pineal growth. most of the tumors present focal presentation related to tumors location.5 in this series, 76% of case present headache, 64% mental changes, 52% vomiting, 46% visual defect, 36% convulsion, 20% completely blind. physical findings can be variable according to tumor type and location. common signs are focal presentation related to location of tumor, and increased intracranial pressure (icp) and abducence and oculomotor nerve defects,. ocular changes are accompaniment of optic glioma pituitary adenoma and pineal growth. endocrine abnormalities may be found in case of pituitary adenoma and pineal tumor. 5 in the present series, 58% cases had icp, 50% visual defects, 46%focal presentation related to tumor location and 32% cases abducence and oculomotor nerve defects. in this study skull radiography and ct scan were done in all patients. skull radiography is poor in detecting brain tumour. intracranial space occupying lesion (icsol) was found in all patients. some degree of hydrocephalus was associated with 30% patients. biopsy and histopathology were also performed in all patients. in this study astrocytomas were found in 40% of cases, among them 22% are grade ii, 10% grade i, 6% grade iii and 4% grade iv (glioblastoma multiforme). pituitary tumors were 16% pineal tumor 6% ependymoma, 4% medulloblastoma 4%, oligodendroglioma 2% and brain stem tumor 2%. allen and chutorian found gliomas 50% of all primary brain tumors and glioblastomas comprise over 50% of all glioma, meningioma constitutes 15% of primary intracranial neoplasm. pituitary adenomas comprise 12% to 18% of intracranial neoplasm, the majority of which are chromo phobic; they are almost never malignant.3,6 walker md found medulloblastoma represents 4% to 8% of all primary brain tumor and ependymomas account for 1% to 8%.4 percentage of gliomas was correlates with the study done by allen and chutorian but the grading of the tumor markedly varies and almost reverse. in the previous study it was found that more than 50% of gliomas are in advanced grade,3 but in this study maximum glioma cases are found in grade i. & ii percentage of pituitary adenoma, meningioma and other tumors well correlate with the previous study. in conclusion in this study most common manifestation of brain tumor was vomiting, convulsion, headache, visual defect, papilloedema, focal neurological sign, oculomotor and abducens nerve defects. one third of the patient had associated hydrocephalus. astrocytoma was the common tumor of brain followed by meningioma and pineal tumour. fig.-2: ct finding of skull in brain tumor (n=50) clinical and pathological characteristics of brain tumor naziruddin mollah et al 70 diagnostic yield of x-ray skull is poor. mri or ct scan should be done in any suspected case of brain tumour. references: 1 . rubin p, mc donald s, qazi r. clinical oncology, 7th edition. philadelphia: we saunders ; 1993. 2 . burger pc, scheithauer bw, vogel fs. surgical pathology of nervous system and its covering, 3rd edition. new york : churehill livingstone; 1991. 3 . allen jc. childhood brain tumors: current status of clinical trials in newly diagnosed and recurrent disease. clin n am. 1996l 32: 633-51. 4 . walker md. brain and peripheral nervous system tumors. in: holland jf, feri e (eds). cancer medicine. philadelphia : lea & febiger; 1993, pp 1385-1417. 5 . kornbilth pl. increased intracranial pressure. in: devita vt, hellmann s, rosenberg sa (eds): cancer: principles and practice of oncology. philadelphia : jb lippincott; 1992, p. 15861588. 6 . chutorian am, grati sr: diagnosis of intracranial tumors in infants and children. in: chang ch, houspian em (eds): tumors of the central nervous system: modern radiotherapy in multidisciplinary management new york, masson publishing 1992, pp 83-125. bsmmu j vol. 3, issue 2, july 2010 71 vol. 3 no. 2, 2010.pmd introduction: coronary heart disease is a life threatening condition for human population. during surgical intervention like coronary artery bypass graft (cabg), median sternotomy is the best approach for a clear visualization of heart & associated viscera. median sternotomy is a type of surgical procedure in which a midline vertical incision is made along the sternum after which the sternum itself is divided or cracked.1 cardiac procedure requiring median sternotomy includes coronary artery bypass grafting, valve replacement, repair of a variety of congenital cardiac diseases. post-sternotomy pain is mostly musculoskeletal & myofascial. these painful conditions are jointly called post sternotomy pain syndrome2. per-operatively it is controlled by large bolus intravenous infusion of opioid viz morphine or fentanyl. thoracotomy, sternotomy and the placement of pleural chest tubes results in considerable pain in the post operative period in patients undergoing cabg 3. traditionally opioids and nsaid are used for post operative pain management after sternotomy. postoperative pain management after sternotomy in off-pump coronary artery bypass graft (cabg) surgery – a comparative study between nsaid (diclofenac sodium) and opioid (pethidine) kamrul hasan1, zerzina rahman2, ayesha sultana1, najib ahsan3 1consultant 2associate professor, 3medical officer, dept. of anesthesia, analgesia & intensive care medicine (cardiac anesthesia wing), bsmmu, dhaka. abstract: background: traditionally, postoperative pain has been managed either reactively with drugs given as needed or proactively with continuous infusion of analgesics. objectives:the present prospective comparative study was carried out to find difference in efficacy between opioid and nsaid (non-stroid anti-inflammatory drugs) in the post-sternotomy pain management following off pump coronary bypass graft surgery. methods: a total of 30 patients were randomly divided into two groups. – 15 patients were treated with nsaid (diclofenac sodium) and 15 patients with opioid (pethidine) which are not commonly used in cardiac surgery. patients ranging from 40 – 60 years with asa grade i & ii who underwent off-pump cabg with median sternotomy were included in the study. statistics: the test statistics used to analyze the data were chi-square test and repeated measure anova. result & conclusion: the study concluded that the intensity of post-sternotomy pain was inappreciably higher in the nsaid group than that in the opioid group throughout the whole period of observation suggesting that opioid (pethidine) would be a promising analgesic in the post-sternotomy pain management than nsaid (diclofenac sodium) (p = 0.045). key words: post-sternotomy pain: opcab: choice of analgesic. [bsmmu j 2010; 3(2): 91-96] address for correspondence: dr. zerzina rahman, associate professor; department of anesthesia, analgesia & intensive care medicine (cardiac anesthesia wing); bangabandhu sheikh mujib medical university, dhaka, bangladesh. e-mail: bannya84@gmail.com inadequate analgesia causes respiratory, haemodynamic, endocrine and metabolic complications. the preferred drugs for postoperative pain management are opioids. pethidine is not a common opioid chosen for pain management after cardiac surgery though it is used as a common post-operative analgesic after general surgery. usually morphine is used for haemodynamic stability after open heart surgery but it has a series of side-effects like nausea, vomiting, constipation, respiratory depression. nsaids are also used for analgesia. it also has some-side effects such as gastro-intestinal disturbance, renal impairment, decreased platelet function, impaired coagulation etc4. in this study we assessed and compared the efficacy of two different analgesics to relieve post sternotomy pain with an assumption that opioid (pethidine) may have better effects than nsaid (diclofenac sodium) in controlling the post-operative pain following sternotomy for opcab (off pump coronary artery bypass) surgery pain is more than just a physical process; it is a complex, subjective phenomenon5. pain can impair the haematologic, immune, hormonal, cardiac, and respiratory systems.6 pain also can limit mobility7, interfere with sleep and rest, and contribute to agitation, psychosis, aggressive behavior, and delirium8. surgical centers need to pay attention to pain management, because there appears to be a direct relationship between unrelieved pain and cost of medical care, time spent in an intensive care unit, and length of hospital stay8. traditionally, postoperative pain has been managed either reactively with drugs given as needed or proactively with continuous infusion of analgesics 9. evidence suggests that reactive pain management is ineffective. with a reactive approach, analgesics are administered at the discretion of nurses and only on an as-needed basis. consequently, treatment takes place after pain occurs 10, causing some patients to experience severe pain11. in contrast, proactive pain management improves effectiveness, because treatment is given before pain occurs10. with a proactive approach, analgesics are often administered via a continuous peripheral or epidural infusion. however, because this approach may entail added risk5, is short-term, high-tech, equipment dependent, and often self-administered, it is neither available nor appropriate for all surgical patients12. methods: the present study was contemplated to compare the efficacy between opioid and nsaid in the poststernotomy pain management following off-pump coronary bypass graft surgery, to see the influence of analgesics on haemodynamic state of the patients following off-pump coronary artery bypass graft surgery, to find out modulation of both early and delayed sequel of pain and to observe the restoration of respiratory function. the present study was a prospective study which was carried out at anesthesiology department (cardiac anesthesia wing) of bangabandhu sheikh mujib medical university, dhaka, over a period of 6 months from january 2009 to june 2009. the study population was the patients scheduled for elective cardiac surgery and underwent off pump cabg with median sternotomy. patients of asa grade i & ii between 40 – 60 years were included in the study. patients, who were not willing to participate in the study; had known contraindication to opioid or nsaid, impaired kidney & liver function and previous operation with median sternotomy were excluded from the study. the demographic variables studied were age, sex and bmi. the safety variables were pulse rate, intra-arterial blood pressure (systolic and diastolic), respiratory rate, spo2 and the outcome variable was intensity of post-sternotomy pain on visual analogue scale (vas). after selecting the patients based on selection criteria, they were divided into two study groups using random allocation procedure in card lottery method. 30 patients were divided into diclofenac (gr. a) and opioid (gr. b)group – each containing 15 patients. the patients of group-a received diclofenac sodium 1 – 2 mg/kg body weight 12 hourly in intramuscular route up to 48 hours, while the patients of group-b received pethidine 1.5 mg/kg body weight 6 hourly in the same route as diclofenac sodium up to the same period. observations were made at 6 hourly intervals up to 48 hours and the findings were compared between the groups to come to a decision which group was better in terms of outcome variable, postoperative intensity of pain. assessment of pain: the uni-dimensional pain scales that can measure pain intensity and are self reported by patients are numerical rating scale, verbal rating scale (vrs) and visual analogue scale (vas). visual analogue scale (vas) involves asking the patients to rate their pain from 0 – 10 (11 points) with the understanding that 0 represents one end of pain intensity continuum (no pain) and 10 represents the other extreme of pain intensity (unbearable pain). the strength of vas is its simplicity and therefore can be used with a great variety of patients. data were collected using a structured questionnaire (research instrument) addressing all the variables of interest. statistical analysis: the test statistics used to analyze the data were descriptive statistics, chi-square (χ2) probability test and repeated measure anova. the level of significance was set at 0.05 and p < 0.05 was considered significant. results: a total of 30 patients scheduled for elective cardiac surgery by off pump cabg with median sternotomy were planned to be treated by nsaid (group-a) and opioid (group-b) for postoperative pain management. changes in pulse, systolic and diastolic blood pressures, respiratory rate, spo2 and pain measured on vas scale of the two groups were compared at 6 hourly intervals after extubation. data analysis demonstrated that no significant difference was found between groups with respect to age and sex distribution (p = 0.241). the mean pulse rates of group-a and group-b were 108/ minute and 107/minute respectively at 6 hours of extubation which decreased to 96/minute and 103/minute respectively at 12 hours interval. then both groups experienced a sharp postoperative pain management after sternotomy in off-pump coronary artery bypass graft kamrul hasan et al 92 rise and sharp fall with decrease of pulse rates to 94 and 99/minute at 24 hours interval. thereafter the variable began to decrease insidiously and stabilized to 85 and 86/ minute in group-a and group-b respectively at the end of 48 hours. the changes in pulse rates were similar in both groups that means there is no significant difference (p = 0.836). fig..-1 depicts the changes in systolic blood pressure (sbp) at different time interval. at 6 hours of extubation, the mean sbps of group-a and group-b were 149 and 132 mmhg respectively and continued decreasing up to 24 hours in group-a and up to 30 hours in group-b. finally the blood pressures stabilized to 115 and 113 mmhg in group-a and in group-b respectively with no significant difference between the groups (p = 0.171). visual analog scale (vas): the intensity of pain measured by visual analog scale (vas) shows that the mean pain score of group-a and group-b were 6.9 and 6.8 respectively at 6 hours of extubation which decreased insidiously to 4.1 and 3.3 at 48 hours. the intensity of pain was significantly higher in the former group than that in the latter group throughout the whole period of observation (p = 0.045) (table viii & fig. 7). table -i pain score in vas scale at different time interval pain on vas group a group b p(0-10 cm) at n =15 n = 15 value 6 hours 6.9 ± 0.4 6.8±0.4 0.63 ns 12 hours 6.3 ± 0.4 6.1± 0.5 0.31 ns 18 hours 5.7± 0.5 5.9± 0.5 0.134 ns 24 hours 5.5± 0.6 5.3± 0.6 0.045 ns 30 hours 5.3± 0.9 4.7± 0.6 0.080 ns 36 hours 4.9±0.7 4.5± 0.7 0.088 ns 42 hours 4.3 ± 0.8 3.5± 0.5 0.004 s 48 hours 4.1± 0.8 3.3 ± 0.4 0.004 s # repeated measure anova statistics was employed to analyze the data and ‘p’ refers to overall differences between groups; s = significant; ns = not significant. fig.-1: monitoring of sbp at different time interval the mean diastolic blood pressure from 6 to 48 hours of observation were significantly higher in group-a than those in group-b (p = 0.021). (fig.-2). fig.-2: monitoring of diastolic bp at different time interval fig.-3 explains the changes of respiratory rate at different time intervals. the rate was 19/minute in group-a and 20/ minute in group-b at 6 hours of extubation. both groups had some ups and downs and finally stabilized to 17/ minute in either group (p = 0.911). fig.-3. monitoring of respiratory rate at different time interval bsmmu j vol. 3, issue 2, july 2010 93 discussion: adequacy of postoperative pain control is one of the most important factors in determining when a patient can be safely discharged from a surgical facility and has a major influence on the patient’s ability to continue their normal activities of daily living.15 perioperative analgesia has traditionally been provided by opioid analgesics viz morphine, fentanyl etc. however, extensive use of opioids is associated with a variety of perioperative side effects, such as ventilatory depression, drowsiness and sedation, postoperative nausea and vomiting (ponv), pruritus, urinary retention, ileus, and constipation that can delay hospital discharge14,17. although these side-effects are not encountered by the opioid group of patients in the present study as the selection of postoperative opioid is different here (pethidine) , we must keep in mind the dangerous side effects of these drugs when planning for postoperative analgesia in individual patients with opioid group of drugs. universally, the goal of peri-operative pain management is to provide a good outcome of surgery. the world health organization (who) has addressed this goal by developing a framework for managing pain. accreditation standards have evolved and now include specific expectations about the management of pain13. intra-operative use of large bolus doses or continuous infusions of potent opioid analgesics may actually increase postoperative pain as a result of their rapid elimination and/or the development of acute tolerance16. in addition; it has been suggested by the joint commission on accreditation of healthcare organizations that excessive use of postoperative opioid analgesics leads to decreased patient satisfaction. partial opioid agonists (e.g., tramadol) are also associated with increased side effects (e.g., nausea, vomiting, ileus) and patient dissatisfaction compared with both opioid 17 and non-opioid18 analgesics. some study reports earlier suggested that parenteral nsaid possessed analgesic properties comparable to the traditional opioid analgesics19 without producing any opioid-related side effects20. compared with the partial opioid agonist tramadol, diclofenac produced better postoperative pain relief with fewer side effects after cardiac surgery21. when administered as an adjuvant during outpatient anesthesia, diclofenac sodium was associated with improved postoperative analgesia and patient comfort compared with fentanyl and the partial opioid agonist, dezocine22. other investigators reported that diclofenac sodium provided postoperative pain relief similar to that of fentanyl but was associated with less nausea and somnolence, as well as an earlier return of bowel function23. in most studies, use of diclofenac sodium has been associated with a less frequent incidence of ponv than the opioid analgesics. as a result, patients tolerate oral fluids and are fit for discharge earlier than those receiving only opioid analgesics during the perioperative period. of interest, diclofenac sodium was superior to a dilute local anesthetic infusion (bupivacaine 0.125%) in supplementing epidural pca hydromorphone in patients undergoing thoracotomy procedures24. furthermore, it has been found that the diclofenac sodium at the incision site in combination with local anesthesia resulted in significantly less postoperative pain, a better quality of recovery, and earlier discharge compared with local anesthesia alone24. in fact, there is evidence for both a peripheral and central analgesic action of nsaid.25 however, when diclofenac sodium was substituted for or combined with fentanyl during minor gynecologic and laparoscopic procedures; the beneficial effects of the nsaid were reduced26. despite the obvious benefits of using nsaids in the perioperative period, controversy still exists regarding their use because of the potential for gastrointestinal mucosal damage and renal tubular and platelet dysfunction27. although some studies have found increased blood loss and risk of reoperation when diclofenac sodium was administered to children undergoing tonsillectomy procedures28. opioid analgesics are a broad group of compounds that includes naturally occurring extracts of opium, synthetic surrogates, and endogenous peptides. opioid receptors are widely distributed, and close voltage-dependent calcium channels, and opens calcium-dependent inwardly rectifying potassium channels, resulting in inhibitory effects characterized by neuronal hyperpolarization and decreased excitability 29. opioids are commonly administered throughout the perioperative period for cardiothoracic procedures. intra-operatively, they are given intravenously as either the primary anesthetic agent or, more commonly, as an adjunct to a mixed anesthetic technique that includes potent inhaled anesthetics, benzodiazepines, and other agents. a primary benefit of effective pain control is patient satisfaction. outcome benefits that involve peri-operative complications appear to be highly related to the analgesia technique used, particularly in relation to the effectiveness in blocking the surgical stress response and nociceptive spinal reflexes. pavlin et al. confirmed that moderate-to-severe pain prolonged recovery room stay by 40–80 min30. use of local anesthetics and nsaids decreased pain scores and facilitated an earlier discharge home. additional outcome postoperative pain management after sternotomy in off-pump coronary artery bypass graft kamrul hasan et al 94 studies are needed to validate the beneficial effect of these non-opioid therapeutic approaches with respect to important recovery variables (e.g., resumption of normal activities, dietary intake, bowel function, return to work). although many factors other than pain must be controlled to minimize postoperative morbidity and facilitate the recovery process8. pain remains a major concern of all patients undergoing elective surgical procedures. opioid analgesics continue to play an important role in the management of moderate-to-severe pain after surgical procedures. however, adjunctive use of non-opioid analgesics will likely assume a greater role as minimally invasive (“key hole”) surgery continues to expand31. in introducing new therapeutic modalities for pain management, it is important to carefully consider the risk: benefit ratio32. use of local anesthetics and nsaids decreased pain scores and facilitated an earlier discharge home. in the present study, diclofenac sodium and pethidine are compared to find a better option, because pethidine is not a common choice for post-operative analgesia in cardiac surgery. but the visual analogue scale found the significance of difference in pain quality between them. the optimal non-opioid analgesic technique for postoperative pain management would not only reduce pain scores and enhance patient satisfaction but also facilitate earlier mobilization and rehabilitation by reducing pain-related complications after surgery. the visual analog scale (vas) has been used to assess the efficacy of pain management regimens in patients with acute postoperative pain. in this study, the intensity of pain measured on visual analog scale (vas 0 – 10 cm) demonstrated that the mean pain intensity of group-a and group-b were 6.9 and 6.8 respectively at 6 hours of extubation which decreased gradually to 4.1 and 3.3 at 48 hours. the intensity of pain was significantly higher in the nsaid group than that in the opioid (pethidine) group throughout the whole period of observation (p = 0.045) indicating that use of pethidine in the post-sternotomy pain management is better and faster than that of nsaid (diclofenac).previous pain experience, anxiety, or anticipated pain with consistency in vas scores. conclusion: from the findings of the study and discussion thereof it could be concluded that the intensity of post-sternotomy pain was significantly higher in the nsaid group than that in the opioid group throughout the whole period of observation suggesting that opioid (pethidine) though uncommon in cardiac surgery, would be a promising analgesic in the post-sternotomy pain management than that of nsaid (diclofenac sodium).it again proves the superiority of opioids as post-operative analgesics over nsaids, though many studies elaborated in discussion proved the efficiency and preference for it. however, our study findings are based on small sample size which lacks generalization. further study with large sample is, therefore, needed to arrive at a definitive conclusion. moreover, the study did not consider the sideeffects encountered by the patients of two study groups. risk benefit ratio of the two study drugs must be weighed before making a general recommendation as to which of the two drugs should be used in the management of poststernotomy pain following off-pump cabg. references: 1 . adam pick 2008. the patient’s guide to heart valve surgery from http:/www. heart valve surgery.com/sternum-brokenpain-healing.php. 2 . rahman akms. management of post cabg pain; bangladesh context, 5 th south asian confederation of anesthesia 2003:302-6. 3 . bainbridge d & martin je. nsid – analgesia, pain control and morbidity in cardiothoracic surgery. canadian journal of anesthesia 2006;53:46-59. 4 . aarhus university hospital, december 2007 from http:/ clinical trials,gov/ct2 show/nct 00572208. 5 . swarm ra, karanikolas m, kalauokalani d. pain treatment in the perioperative period. cur probl surg. 2001;38:8359 2 0 . 6 . dracup k, bryan-brown c. pain in the icu: fact or fiction? am j crit care.1995;4:337-9. 7 . watt-watson j, stevens b. managing pain after coronary artery bypass surgery. j cardiovasc nurs. 1998;12:39-51. 8 . kehlet h. acute pain control and accelerated postoperative surgical recovery. surg clin north am. 1999;79:431-43. 9 . kruger m, mcrae k. pain management in cardiothoracic practice. surg clinnorth am. 1999;79:387-400. 1 0 . melzack r. the tragedy of needless pain. sci am. 1990;262:27-33. 1 1 . carroll kc, atkins pj, herold gr, et al. pain assessment and management in critically ill postoperative and trauma patients: a multisite study. am j critcare. 1999;8:105-17. 1 2 . pasero c, mccaffery m. multimodal balanced analgesia in the critically ill. crit care nurs clin north am. 2001;13:1952 0 6 . 1 3 . cancer pain relief and palliative care: report of a who expert committee. geneva, switzerland: world health organization; 1990:1-75. world health organization technical report series, 804. bsmmu j vol. 3, issue 2, july 2010 95 1 4 . white pf. ambulatory anesthesia advances into the new millennium. anesth analg 2000;90:1234–5. 1 5 . chung f, ritchie e, su j. postoperative pain in ambulatory surgery. anesth analg 1997;85:808–16. 1 6 . guignard b, bossard ae, coste c, et al. acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. anesthesiology 2000;93:409–17. 1 7 . silvasti m, svartling n, pitkanen m, rosenberg ph. comparison of intravenous patient-controlled analgesia with tramadol versus morphine after microvascular breast reconstruction. eur j anaesthesiol 2000;17:448–55. 1 8 . rawal n, allvin r, amilon a, et al. postoperative analgesia at home after ambulatory hand surgery: a controlled comparison of tramadol, metamizol, and paracetamol. anesth analg 2001;92:347–51. 1 9 . yee jp, koshiver je, allbon c, brown cr. comparison of intramuscular ketorolac tromethamine and morphine sulphate for analgesia of pain after major surgery. pharmacotherapy 1986;6:253–61. 2 0 . ding y, white pf. comparative effects of ketorolac, dezocine and fentanyl as adjuvants during outpatient anesthesia. anesth analg 1992;75:566–71. 2 1 . immer ff, immer-bansi as, tachesel n, et al. pain treatment with a cox-2 inhibitor after coronary artery bypass operation: a randomized trial. ann thorac surg 2003;75:490–5. 2 2 . ramirez-ruiz m, smith i, white pf. use of analgesics during propofol sedation: a comparison of ketorolac, dezocine, and fentanyl. j clin anesth 1995;7:481–5. 2 3 . wong hy, carpenter rl, kopacz dj, et al. a randomized double-blind evaluation of ketorolac tromethamine for postoperative analgesia in ambulatory surgery patients. anesthesiology 1993;78:6–14. 2 4 . coloma m, white pf, huber pj, et al. the effect of ketorolac on recovery after anorectal surgery: iv versus local administration. anesth analg 2000;90:1107–10. 2 5 . romsing j, moiniche s, ostergaard d & dahl jb. local infiltration with nsaids for postoperative analgesia: evidence for a peripheral analgesic action. acta anaesthesiol scand 2000;44:672–83. 2 6 . liu j, ding y, white pf, et al. effects of ketorolac on postoperative analgesia and ventilatory function after laparoscopic cholecystectomy. anesth analg 1993;76:1061– 6 . 2 7 . souter a, fredman b, white pf. controversies in the perioperative use of nonsteroidal antiinflammatory drugs. anesth analg 1994;79:1178–90. 2 8 . gunter jb, varughese am, harrington jf, et al. recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. anesth analg 1995;81:1136–41. 2 9 . bovill jg. update on opioid and analgesic pharmacology.anesth analg2001; 92:s1–s5. 3 0 . pavlin dj, chen c, penaloza da, et al. pain as a factor complicating recovery and discharge after ambulatory surgery. anesth analg 2003;97:1627–32. 3 1 . white pf. the role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. anesth analg 2002;94:577–85. 3 2 . white pf. changing role of cox-2 inhibitors in the perioperative period: is parecoxib really the answer? anesth analg 2005;100:1306–8. bsmmu j vol. 3, issue 2, july 2010 96 vol. 4 no. 2, 2011.pmd introduction: salivary gland neoplasm constitute about 10% of all head & neck neoplasm which represent 3% of all neoplasm of the body. the value of fnac in the investigation of salivary gland disease has been widely debated amongst clinicians and cytopathologists1,5 fine needle aspiration cytology (fnac) of suspected salivary gland lesions has an established role in preoperative diagnosis and management of patients. however diverse morphological patterns and overlapping features make it a challenging job, to give a precise diagnosis, at times2. the aim of the present study is to evaluate the effectiveness of fnac in the diagnosis of parotid gland masses. fine needle for diagnostic technique that is widely employed for lesions of the head and neck. among head and neck sites, the parotid gland is unique in the number, diversity, and peculiarity of its pathological processes. this complexity has prompted a great deal of discussion regarding the diagnosis of parotid gland mass by the fine needle aspiration cytology (fnac) and it’s histopathological correlation 2 years study in bsmmu, dhaka a allam choudhury1, tuhin sultana2, belayat hossain siddique3, a. sufi ahmed amin4 1associate professor, dept of otolaryngology and head neck surgery, 2associate professor dept of clinical pathology, 3professor, dept of otolaryngology and head neck surgery, 4professor, dept of otolaryngology and head neck surgery, bangabandhu sheikh mujib medical university, shahbag, dhaka, bangladesh abstract: background: fine needle aspiration cytology is a widely practiced technique in the diagnosis of parotid lump. fine needle aspiration cytology (fnac) is a simple, quick, inexpensive and minimally invasive technique used to diagnose different types of masses. in otolaryngology, fnac’s greatest utility is in the diagnosis of neck masses.objectives: the aim of this study was to assess the sensitivity and specificity of fnac in the diagnosis of parotid mass. parotid gland lesions form about 2-6.5% of all head and neck neoplasms in adults. they are easily accessible by fnac, also cytology can provide a distinction between parotid and non-parotid lesion, benign and malignant lesions, and specific and non specific inflammation. methods: 50 patients were studied prospectively over 2 years. fnac was done using 10 cc syringes and 20-22 g. needle and stained with papanicular stain. histopathology was assessed on routine h & e (haematoxylin and eosin) stained paraffin sections. results: sensitivity and specificity for diagnosing malignant and benign tumours were 75%, 95.2%, and 92.5%, 80%, respectively, and 90% of benign tumours were accurately typed on fine-needle aspiration cytology compared with 92% in the malignant group. conclusion: fine-needle aspiration cytology is useful in the preoperative assessment of parotid tumours as it is more reliable than clinical examination to diagnose malignant parotid tumours. fna cytology is useful in avoiding surgery (inflammatory lesions) or limiting surgical procedures (benign tumours). key words: parotid gland tumour, fine needle cytology [bsmmu j 2011; 4(2):65-69] address for correspondence: a allam choudhury, associate professor, dept of otolaryngology and head neck surgery, bangabandhu sheikh mujib medical university, shahbag, dhaka, bangladesh application of fnac to parotid masses. primarily focusing on the reliability of fnac as a diagnostic tool in guiding patient management. parotid gland lesions form about 26.5% of all head and neck neoplasm in adults, and present as enlarged masses which are usually accessible for fnac3. they are not generally subjected to incisional or needle biopsy techniques because of the risks of fistula formation, or in the case of neoplasm, of tumour implantation. there is no evidence that these complications occur with fnac2. the present study was undertaken to evaluate parotid gland lesions by fnac and to correlate the cytologic findings with histopathology. cytology can clearly distinguish between parotid and non parotid lesions, benign and malignant lesions, so also specific and non specific inflammation. thus it provides decisive direction for therapeutic management of the patient. fnac is a utility tool for subtyping of parotid gland lesions with variable specificity and sensitivity4. the overall accuracy of fine needle aspiration cytology was 87%, false-positive and false-negative rates for malignant disease both being 4%. the sensitivity, specificity and accuracy of fine needle cytology for malignant parotid tumours was 66%, 95%, and 91%, respectively, that of benign tumours (pleomorphic adenoma or warthin’s tumour) being 88%, 83% and 87%, respectively. sensitivity, specificity and accuracy for the remaining principally inflammatory parotid diseases was 100%, 95% and 96% respectively. the predictive value of a positive test for malignant tumours, benign tumours and inflammatory conditions was 66%, 94% and 75%, respectively. the negative predictive value for these conditions was 95%, 71% and 100%, respectively 3. the benefit of fine needle aspiration cytology in parotid diseases is debated, some claiming it alters clinical decision making in over one third of cases1,4. improvements in radiological assessment have occurred with the use of ultrasound and ct scanning, nuclear magnetic resonance imaging and digital subtraction sialography 6. fine-needle aspiration cytology (fnac) has gained widespread acceptance and popularity among head and neck surgeons in the assessment of thyroid and neck masses but its use in the evaluation of parotid tumours has not attained similar enthusiasm. the main reason in the belief that the presence of a paroitid lump is an indication for its removal.7 further more, the sensitivity and specificity of fnac for parotid tumours is between 57-98% and 86-100%, respectively, and hence, some authors believe that it is not accurate enough to influence the decision-making process.8 the objective of this study is to assess the sensitivity and specificity of fnac in the diagnosis of malignant and benign neoplasms and to evaluate its usefulness in an algorithm in the management of parotid tumours. if the correlation of fnac and histological diagnosis is significant then by doing the preoperative cytological diagnosis the clinician can start the initial treatment and plan the mode of treatment. also it can prevent excess morbidity associated with over treatment methods: this a prospective study done in department of otolaryngology-head & neck surgery and pathology, bsmmu from july 2007 to august 2009. 50 cases of parotid mass were selected by method of randomization which were later on operated. fnac were carried out in 50 cases preoperatively and findings were correlated with final histopathological report. detailed clinical history, results of local examination, general examinations and systematic examination were recorded in each case. fnac was done using 10 cc syringes with 20-22 g. needles after taking informed consent of the patient. smears were stained with papanicolous stain. excisional biopsy specimens were fixed in 10% formalin. gross and microscopic examination were performed in each case. h& e stain was done in all cases. fine-needle aspiration cytology results were classified into the following categories: benign, malignant and nonneoplastic lesions. the corresponding cytological and histological diagnosis were reviewed retrospectively and analysed. study design included a comparison between results of preoperative fnac with final histopathological diagnoses. data analysis was calculated sensitivity and specificity of fnac in differentiating between benign and malignant lesions. results: 50 patients having both preoperative fnac and final histopathological diagnosis constituted the study group. there were 32 men and 18 women in an age range of 12-77 years (mean 48.7 years). 41 patients underwent superficial parotidectomy, and 9 total parotidectomy. most of the benign tumour are pleomorphic adenoma (68%) fig-1 shows a patient of pleomorphic adenoma of parotid gland. fig-2 shows fine needle aspiration cytology picture of pleomorphic adenoma. fig-1: pleomorphic adenoma of parotid gland. diagnosis of parotid gland mass by the fine needle aspiration cytology (fnac) choudhury et al 66 most of the malignant tumours are adenocystic (10%) & then mucoepidermoid (6%) carcinoma. fig-3 & 4 show adenocystic and mucoepidermoid carcinoma fnac picture respectively. the results of fnac showed that 39 (78%) were benign, 9(18%) were malignant and 2(4%) non-neoplastic lesion. final histological diagnosis confimed the presence of 8 (16%) malignancies, 40 (80%) benign tumours 2 (4%) nonneoplastic lesion. (table-i). fig-2: fnac picture of pleomorphic adenoma. fig-3: fnac picture of adenocystic carcinoma fig-4: fnac picture of mucoepidermid carcinoma. table-i histopathological & cytological diagnoses of 50 cases histological cytological diagnosis diagnosis benign 80% 78% pleomorphic adenoma 35 33(2 adenocystic carcinoma) warthin’s 4 3 (1 diagnosed as tubercular lesion) lipoma 1 1 malignant 16% 18% carcinoma in pleomorphic adenoma 1 (1 diagnosed as pleomorphic adenoma) adonocystic carcinoma 4 3(1diagnosed as malignant neoplasm \of uncertain type mucoepidermoid carcinoma 3 3 non-neoplastic 4% 4% benign lymphoepithelial cyst 1 1 tubercular intraparotid lymph node 1 (1 diagnosed as warthin’s tumour) total 50 50 bsmmu j vol. 4, issue 2, july 2011 67 fine-needle aspiration cytology did not correlate with 6 specimens of which 3 were benign, 3 were malignant. so accuracy of benign tumour by fnac was 90% & malignant tumour was 92%. sensitivity and specificity of benign tumour 92.5% and 80% & malignant tumour 75% & 95.2%. so cytological diagnosis were 88% correlate with histological diagnosis. (table-ii). table-ii histopathological & cytological analysis of 50 cases. sensitivity specificity accuracy benign 92.5% 80% 90% malignant 75% 95.2% 92% discussion: fine-needle aspiration (fna) is a safe diagnostic technique that is widely employed in the examination of parotid masses at relatively low cost and minimal risk to the patient. preoperative diagnosis of benign and malignant tumour are important for the surgeons .the standard surgical treatment for most benign tumours in the superficial lobe is lateral parotidectomy, while benign tumours in the deep lobe are usually treated by total parotidectomy with facial nerve preservation. 6 conservative surgical modalities for benign tumours, such as extracapsular dissection, partial lateral parotidectomy, and deep lobe parotidectomy with preservation of the superficial lobe, have been discussed in the literature. 7,9 early primary parotid carcinomas of the superficial lobe are treated in many centres by total parotidectomy, while superficial parotidectomy is performed in other centres. elective neck dissection for primary parotid carcinomas of the clinically negative neck is performed routinely by only a few authours.2 however, most authors advocate neck dissecion on the basis of the histological type of the carcinoma and tumour grade. therefore, selection of appropriate surgical procedure is dependent upon whether a tumour is benign or malignant on preoperative cytological diagnosis. in the present study, male preponderance was observed. there were 40 (80%) benign neoplastic cases. the incidence of benign neoplasm has been reported as 40%, 61% and 69% by different authors.3,4,6 16% of our cases were malignant lesions as against 6%, 37% and 13% reported by other authors(2,4,6). 4% percent of cases were non neoplastic. most common benign tumour was pleomorphic adenoma and most common malignant tumour was adenoid cystic carcinoma in this study. among the parotid malignancy, 3 were mucoepidermoid carcinoma & 1 was carcinoma in pleomorphic adenoma. mucoepidermoid tumour in this study was the second common malignant tumour which correlates with others study. 2.8 neoplasm of salivary gland may occur at any age, marshall and miles (1974) showed malignant tumours usually appear in later age group but may be seen in the adolescents. in this study highest number of patients were in the 5th decade (26%) which correlate with other studies. 2,7 regarding the sex distribution of different neoplasms, benign parotid tumours was more common in male (m:f=1.8:1). malignant parotid neoplasms was also more common in male (m:f= 1.8:1). the benign tumour generally have no pain or other distressing symptoms for which they do not care for it. moreover they fear for the operative treatment. in under developed countries like us, due to poor socioeconomic conditions and non availability of modernized hospital facilities nearby-patient often report to local quackes and village doctors for their treatment before attending to a concerned specialist, for this reasons patient often reports late and sometimes with complication of the disease. in present series, most patients reported-within 4 to 8 years of the diseases. in the present series, all the cases presented with swelling. size of the swelling in most pleomorphic adenoma were more than 2 cm and malignant tumours varied between 2 to 4 cm. patient with longer duration & larger swelling presented in more advanced stage. most of the patient of malignant tumours admitted in the hospital at stage-3 is supported by others.8 regarding investigation in present series, fnac was done in all 50 cases (100%). out of which 44 cases of cytological diagnosis correlate with histological diagnosis. post operatively 50 cases were confirmed by histopathological examination. in cases of warthin’s tumour, cristallinins showed 90.1% fnac correlation with histopathological examination10. in our series, we diagnosed 4 cases of warthins tumour by fnac and one case was diagnosed as tubercular lesion.3 later on 4 cases were confirmed as warthin’s tumour on histopathology. in cristallinins study, a diagnosis of non neoplastic lesion was given in two cases, which tuned out to be warthin’s tumour on histology.9 but in this study, out of two non neoplastic lesions one was diagnosed as warthin’s tumour on histopathology. diagnosis of parotid gland mass by the fine needle aspiration cytology (fnac) choudhury et al 68 in this study sensitivity and specificity for diagnosing malignant and benign tumours were 75%, 95.2%, and 92.5%, 80%, respectively, and 90% of benign tumours were accurately typed on fine-needle aspiration cytology compared with 92% in the malignant group. accuracy of benign tumour 90% and malignant tumour 92%. other study shows sensitivity and specificity of malignant and benign were 80%, 100% & 98.5% 87.5%,1 66%, 95% & 88%, 83% respectively.2 fnac has a sensitivity & specificity of neoplastic lesion 94.54%,80.95%,6 and 79%, 84% respectively.3 in some report, the accuracy rate for detecting malignant parotid tumours ranged from 79% to 97%, sensitivity from 54% to 95%, and specificity from 86% to 100%.9 many authors have reported its usefulness as a diagnostic tool, with documented accuracy rates ranging from 97% to 98% for the large and diverse group of neoplastic and inflammatory lesions involving the parotid gland, 1,5 recent studies have reported overall accuracy rates of fna for parotid masses ranging from 90% to 95% well within the range of 81% to 98% established in earlier studies. in fact, das et al, reported that fnac recognised the malignant nature of only 60% of salivary gland carcinomas, even though the specificity and accuracy of fnac were excellent 95% and 90% respectively. in some comparative study, zbaren et al. analysed 110 parotid tumours, 68 malignancies, and 42 benign tumours and reported that the accuracy, sensitivity, and specificity of fnac for detecting malignant tumours were 97%, 74% and 88%, respectively.10 regardless of one’s position regarding the use of fnac as a routine or selective tool for evaluating parotid masses, utilisation should be moderated by a number of general principles. first, the primary value of fnac is to establish the need for definitive surgery, not to establish a specific diagnosis. second, for decisions regarding the extent of parotid surgery, such as whether to spare or sacrifice the facial nerve, fnac diagnosis plays a subordinate role to intraoperative findings. third, in those instances in which cytological and clinical impressions deverge, intraoperative frozen section findings remain an important arbitrator. fnac is a safe, cost effective, quick and easy diagnostic procedure that causes little discomfort to the patient. fine needle aspiration cytology is a valuable adjunct to preoperative assessment of parotid masses as save, noninvasive procedure, almost without contraindications. the high rate of specifity of fnac presents low possibility that benign cytological diagnosis of parotid tumors become malignant in final histopathological diagnosis. preoperative recognition of malignant tumors may help prepare both the surgeon and patient for appropriate surgical procedure. conclusion: the use of fnac in the pre-operative evaluation of the patient with a parotid mass is likely to influence management where the clinical features suggest the possibility of a benign or malignant. fine-needle aspiration cytology is useful in the preoperative assessment of parotid tumours as it is more reliable than clinical examination along to diagnose malignant parotid tumours. although it may not accurately type the malignant tumours, the diagnosis of malignant tumours preoperatively may allow for appropriate surgical planning by the surgeon. fnac was found to be simple, noninvasive and cost effective and rapid diagnostic tool for parotid gland lesions. it plays a key role in evaluation of parotid gland tumours thus helping further surgical management of the patient. we recommend that, where clinical teams use the results of fnac to influence management of a primary parotid neoplasm, caution should be exercised and on going audit of the performance of fnac is required within each institution. references: 1 . chwee ml, juliana t, kwok sl, siew sc, lynne hyl, luke kst. ‘role of fine-needle aspiration cytology in the evaluation of parotid tumours’. anzj. surg, 2007; 77: 742-744. 2 . gordon td, kevin b, roy a j s. an audit of surgery of the parotid gland. ann r coll surg engl, 1995; 77: 188-192. 3 . balakrishnan k, mcmahon j, imric j, feeley km, parker aj, bull pd. fine needle aspiration cytology in the management of a paroitid mass. a two centre retrospective study. the surgeon, 2005; 3:2: 67-72. 4 . howlett dc. diagnosing a parotid lump: fine needle aspiration cytology or core biopsy?. the british journal of radiology, 2006;79: 295-297. 5 . kotwal m, gaikwad s, r patil, munshi m, bobhate s. fnac of salivary gland – a useful tool in preoperative diagnosis or a cytopathogist’s riddle?. journal of cytology, 2007;24:2:85-88. 6 . khandekar mm, kavatkar an, patankar sa, bagwan ib, puranik sc, deshmukh sd. ‘fnac of salivary gland lesions with histopathological correlation. india journal of otolaryngology and head and neck surgery, 2006;58:3:2462 4 8 . 7 . mohammed si, azharul i, abdus s, ekramuddula afm, hossain i h. ‘malignant salivary gland neoplasm clinicopathological study. bangladesh j of otorhinolaryngology, 2008;14:1:1-5. 8 . attilio cs, paolo c, pierantonio b. marco c. ‘usefulness of fine-needle aspiration in parotid diagnostics. oral maxillofac surg, 2009;13:185-190. 9 . cristallinin eg, ascani s, farabi r. fine needle aspiration biopsy of salivary gland. acta cytol, 1997;41:5: 1421-1425 1 0 . ademar t j, danyel e c, jose m, oslei p a, luiz p k. giant pleomorphic adenoma of the parotid gland. med oral patol oral cir bucal, 2008; 13:1. 58-60. bsmmu j vol. 4, issue 2, july 2011 69 vol. 4 no. 2, 2011.pmd introduction: patients with acromegaly have been reported to have about 30% higher mortality rate, and cardiovascular disease accounts for 60% of the deaths. we are reporting a case of a patient with acromegaly who was diagnosed with severe cardiac failure at the time of diagnosis and had marked clinical improvement after the successful resection of the pituitary adenoma. immediate diagnosis and treatment are required for better control of acromegalic heart failure. case report: a 70 years old lady presented with a short history of dyspnoea (nyha iv). on query she admitted that she noticed progressive enlargement of acral parts, coarsening and enlargement of face for 7 years, orthopnoea and palpitation for 3 months and new onset of diabetes mellitus and hypertension for 1 month . she also had excessive sweating and knee joint arthalgia but gave no history of headache, visual impairment, nasal discharge or any limb weakness. clinical examination revealed acromegalic facies, enlarged acral parts, thyromegaly, features of cardiomegaly with mitral regurgitation, controlled b.p (with medication), and husky voice. fundus examination and visual evaluation were unremarkable. serum gh level was 15.0 ng/ml at basal level, and serum prolactin, tsh, ft4 were within normal limit. x-ray skull showed apparently normal size sella without any erosion but mri of pituitary gland showed pituitary microadenoma. x ray hand showed increased soft tissue shadow with enlargement of hand bones with tufting of terminal phalanges with periarticular osteopenia. x ray acromegaly presenting as cardiac failure a case report shohael mahmud arafat1, mahammad abul kalam azad2, rezwanur rahman3, mehruba alam ananna4 , ahmed manzurul aziz5, quazi mamtazuddin ahmed6, muhammad khaled hasan 7, abm abdullah8 1associate professor, 2medical officer, 3resident, department of medicine, bsmmu, dhaka.4registrar , birdem 5medical officer, singair health complex6assistant professor, department of medicine,7medical officer. department of neurolgy, 8 professor and dean, department of medicine, bsmmu, dhaka. abstract: acromegaly is characterized by chronic hypersecretion of growth hormone (gh) and is associated with increased mortality rate because of the potential complications such as cardiovascular disease, respiratory disease, or malignancy, which are probably caused by the long-term exposure of tissues to excess gh, for at least 10 years, before diagnosis and treatment. here we are reporting a case of acromegaly who initially presented with features of left ventricular failure for which she got herself admitted in ccu and was treated conservatively. later on, after clinical examination and investigations she was diagnosed as a case of mitral regurgitation due to cardiomyopathy caused by acromegaly. after the successful transsphenoidal resection of the pituitary microadenoma, the level of gh was normalized and heart failure improved. key words: acromegaly, heart failure, pituitary microadenoma. [bsmmu j 2011; 4(2): 122-124] address of correspondence: dr shohael mahmud arafat, dept of medicine,bsmmu, dhaka e mail: arafatdr@yahoo.com foot shows increased heel pad thickness. cxr revealed cardiomegaly with scoliosis. echocardiography showed systolic dysfunction with e.f 40% with moderate mitral regurgitation. after confirmation of the diagnosis of acromegaly due to pituitary microadenoma transsphenoidal endoscopic pituitary surgery was done following stabilization of cardiac function. after successful surgery tissue was sent for histopathology which showed pituitary neoplasm composed of fairly uniform polygonal cells arranged in sheets. the cells had abundant eosinophilic cytoplasm and supporting connective tissue stroma was scarce. post operative growth hormone level came down to normal with uneventful postoperative recovery. the patient was discharged at home on 9th post operative day. fig.-1:x ray foot shows increased heel pad thickness. discussion: acromegaly is a consequence of chronic growth hormone (gh) excess, due in the majority of cases to a gh-secreting pituitary adenoma, and occurring with a population prevalence of 60 per million and an incidence of 3-4 per million per year1. males and females appear to be equally affected with an average age of presentation of 44 years1. considerable evidence suggests acromegaly can cause specific type of cardiomyopathy which can result in structural and functional abnormalities resulting in heart failure. this may be partially reversed by effective reduction in gh and igf-1 levels 2, the patient in this report had massive cardiomegaly with a cardiothoracic ratio of <0.9. in acromegaly, cardiac enlargement is a consistent finding and seems to be disproportionate, compared with the increase in size of other internal body organs.2 an increased frequency of systemic hypertension and premature coronary artery disease have also been described. 2 epidemiological study showed that in patients with acromegaly, valvular abnormalities are more prevalent than in control subjects, who were individually matched for left ventricular function, age, sex, and the presence of hypertension3. in addition, it has been found that in acromegalic cardiomyopathy myocardial hypertrophy with interstitial fibrosis, lymphomononulear infiltration, and areas of monocyte necrosis resembling myocarditis are prominent histopathological features. these changes often result in increased left ventricular mass and concentric hypertrophy. 2, 4 left ventricular hypertrophy occurs first, often leading to slow deterioration of diastolic function early in the disease.5,6 this finding has been reported in acromegalic patients even with disease duration shorter than five years. 7.8our patient developed overt heart failure at the age of 70 years with clinical features of acromegaly for almost seven years. then she suddenly developed heart failure. clinically evident congestive heart failure may develop when the disease is untreated or unsuccessfully treated.7 our patient sought medical attention because of severe symptoms of congestive heart failure. data are limited on clinically evident heart failure in acromegalics. damganovics et al reported high-output failure in 10% of patients, while hayward et al found only 7 out of 256 patients (<1%) with clinically evident heart failure. 9.10 echocardiographic findings in this patient showed significant increase in end-systolic and end-diastolic dimensions, reduction in the ejection fraction and fractional shorting, and reversal of the e/a ratio, in the presence of severe signs of congestive heart failure. these echocardiographic features have been documented in young acromegalics without any clinical evidence of cardiac impairment. 7 cardiac dysrhythmias have been documented in a few reports, due to the left ventricular remodeling that occur in this disease.11, 12 however, our patient did not present with any form of ventricular arrythmia. in the absence of other causes of heart failure and mitral regurgitation in this case, we think that her heart failure was caused by acromegalic cardiomyopathy, although we couldn’t confirm it by myocardial biopsy. treatment of acromeagly presenting with heart failure is aimed at removing the source of gh hyper secretion or at fig.-2: x ray hand showing increased soft tissue shadow with bony enlargement and tufting of terminal phalanges. fig.-3: histopathological examinationshowing pituitary neoplasm composed of fairly uniform polygonal cells arranged in sheets. bsmmu j vol. 4, issue 2, july 2011 123 suppressing its activity along with other supportive treatment for heart failure. somatostatin analogues are effective as first-line therapy and have a success rate of 45%– 65%.13, 14. besides this, surgery and local irradiation are other options of treatment. our patient was, however, treated surgically which made a good symptomatic recovery of her heart failure. conclusion: though classically acromegaly patients commonly presents with progressive enlargement of limbs and coarsening of faces but rarely it may present with obvious heart failure caused by cardiomyopathy. so we need to look for endocrine cause of heart failure like acromegaly when there is no other overt cause of failing heart. references: 1 . i m holdaway, c rajasoorya .epidemiology of acromegaly. pituitary. 1999 jun; 2 (1):29-41 2 . sacca l, cittadini a, fazio f. growth hormone and the heart. endocrine rev. 1994; 15:555–573. 3 . sjoerd w. van thiel, alberto m. pereira, jonathan r. lindner, ferdinand roelfsema, ernst e. van der wall, hans morreau et al. increased prevalence of regurgitant valvular heart disease in acromegaly. journal of clinical endocrinology & metabolism 2004:89(1):71-75 4 . frustaci a, chimenti c, setoguchi m, et al.cell death in acromegalic cardiomyopathy. circulation. 1999;99:1426– 1434. 5 . bertoni pd, morandi g. impaired left ventricular diastolic function in acromegaly:an echocardiographic study. acta cardiol.1998;42:1–10. 6 . colao a, cuocolo a, marzullo p, et al. impact of patient’s age and disease duration on cardiacperformance in acromegaly: a radionuclideangiography study. j clin endocrinol metab. 1999; 84: 1518–1523. 7 . colao a, merola b, ferone d, lombardi g. acromegaly. j clin endocrinol metab.1997;82:2777–2781. 8 . olao a, baldelli r, marzullo p, et al. systemic hypertension and impaired glucose tolerance are independently correlated to the severity of acromegalic cardiomyopathy. j clin endocrinol metab. 2000;85:193–199. 9 . damjanovics ss, neskovic an, petakov ms, et al. high output heart failure in patients with newly diagnosed acromegaly. am j med. 2002;112:610–616. 1 0 . hayward rp, emanuel rw, nabarro jdn. acromegalic heart disease: influence of treatment of acromegaly on the heart. q j med. 1987;62:41–58. 11. rodrigues ea, caruana mp, lahiri a, nabarro jdn, jacobs hs, raftery eb. subclinical cardiac dysfunction in acromegaly: evidence for a specific disease of heart muscle. british heart j. 1989;62:185–194. 1 2 . kahaly g, olshausen kv, mohr–kahaly s, et al. arrythmia profile in acromegaly. eur heart j. 1992;13:51–56. 1 3 . abs r, verhelst j, maiter d, et al. carbergoline in the treatment of acromegaly: a study in 64 patients. j clin endocrinol metab. 1997; 82:518–523. 1 4 . chanson p, leselbaum a, blumberg j, et al. efficacy and tolerability of long-acting somatostatin analogue lanreotide in acromegaly.a 12-month multicenter study of 58 acromegalic patients. pituitary. 2000; 2:269–276. acrmegaly presenting as cardiac failure a case report arafat et al 124 vol. 4 no. 2, 2011.pmd introduction: skeletal tuberculosis (tb) usually constitutes 1–3% of extrapulmonary tb, and spinal involvement is about half of them.1 tb of the cervical spine is so unusual that it comprises only 3% of cases of pott’s disease. in addition, retropharyngeal abscess as a presenting manifestation of tuberculosis of the cervical spine is rare.2 the most dangerous area for skeletal tb is the cervical region, due to the greater risk of quadriplegia and death.3 this article describes an extremely rare case of multifocal pott’s disease, along with retropharyngeal and paravertebral abscess. case report: a 13-year-old boy had 7½ months history of fever, anorexia, weight loss, and cervical lymphadenopathy with discharging sinus. initially he was admitted in a tertiary care hospital, where, a ct scan of chest & neck revealed “retropharyngeal, pre & paravertebral abscess, multiple vertebral destruction, and cervical & right paratracheal lymphadenopathy” (figure 1). for the last 6 months, he was on supervised anti-tb chemotherapy on the basis of fnac of cervical lymph node which revealed caseating granuloma. despite getting anti-tb drugs, and symptomatic improvement in terms of resolution of fever, improvement of appetite and weight, he developed neck pain along with quadriplegia, 5 days before presenting to us. on admission, both his upper and lower limb power was 0/ 5 with complete sensory loss up to c2 and absent deep tendon reflexes with equivocal plantar response. multifocal extensive spinal tuberculosis with retropharyngeal abscess farzana shumy1, ahmad mursel anam2, m a jalil chowdhury3, md. abul kalam azad2, samsun nahar2 1medical officer, 2post graduate trainee and 3professor, department of medicine, bangabandhu sheikh mujib medical university, shahbag, dhaka-1000, bangladesh. abstract: an unusual case of a young boy presenting with spinal tuberculosis involving cervical & thoracic vertebrae, along with retropharyngeal abscess is reported. the patient presented with progressive quadriparesis, fever, night sweat and cervical lymphadenopathy. the lab studies confirmed tuberculosis and patient received anti-tubercular chemotherapy. after development of quadriparesis, spinal surgery was done. the post operative course was uneventful and the patient is on gradual neurological recovery. [bsmmu j 2011; 4(2): 128-130] address for correspondence: farzana shumy, house # 61/b, road # 6/a, dhanmondi ra, dhaka 1209, bangladesh. e-mail: farzanashumy@hotmail.com he had raised esr (85 mm in the 1st hour) with positive mantoux test (20 mm after 72 hours). mri of cervical & dorsal spine, done this time, showed “c4 & d4 vertebral body heights are reduced with anterior wedging causing localized kyphotic deformity with epidural extension of the perivertebral mass resulting in cord compression. disk space between c4-c5 and d4-d5 are obliterated. perivertebral mass at craniovertebral junction to c5 level and d2 to d4-5 level with epidural extension present. atlanto-axial subluxation with an intervening mass are causing further cord compression (impression: features are suggestive of tubercular spondylodiscitis at multiple levels with epidural mass causing cord compression)” (figure 2). all other biochemical investigations, including random blood sugar, were normal. histopathological examination of tissue from intervertebral disc and paravertebral region of c3-c4 region showed caseating granuloma. fig.-1: ct scan of chest showing paravertebral abscess (arrow). . to manage quadriplegia, trans-oral and trans-cervical decompression of spinal cord at c2,3,4 level and fusion of loose graft was done. he was already on continuation phase of anti-tubercular chemotherapy. after surgery, patient regained his upper limb power and sensory function of all limbs. discussion: the retropharyngeal space is a potential space in the fascial planes between the prevertebral and buccopharyngeal fascia.2 tuberculous retropharyngeal abscess is usually a consequence of chronic tb of the cervical spine, because pus spreads directly through the anterior longitudinal ligament.4 our patient’s presenting features, like neck pain and retropharyngeal abscess and collapse of cervical vertebrae, as demonstrated in ct scan, can be explained in this manner. primary focus in the lungs or the lymph nodes acts as a source for haematogenous dissemination, resulting in spinal tuberculosis.5 in this case; the patient had cervical lymphadenopathy as well as right paratracheal lymphadenopathy, either of which can be responsible. three recognized patterns of vertebral body involvement are paradiskal, anterior and central lesions. paradiskal lesion, adjacent to the vertebral body, leads to narrowing of disc space. central lesion targets the vertebral body without involving disc. anterior lesions are subperiosteal lesions under the anterior longitudinal ligament. the central type spreads along the batson’s plexus of veins, while paradiskal infection spreads through the arteries. the anterior type of vertebral body tuberculosis results from the extension of the abscess beneath the anterior longitudinal ligament and periosteum. pus spread over multiple vertebral segments, stripping the periosteum and anterior longitudinal ligament from anterior surface of vertebral bodies. mri image shows abnormal signal involving multiple vertebral segments.6 these, probably, were the processes, in which multiple vertebral involvement, along with perivertebral abscess in both cervical and thoracic region, took place in our patient, although extensive bone destruction involving multiple vertebrae is an uncommon finding in tuberculous spondylitis. spinal tuberculosis likes to target the thoracic and the lumbar spine; involvement of the cervical region and sacrum is less common.7 as cross-sectional diameter of the spinal canal is relatively smaller than the diameter of the cervical cord; neurologic deficits are easier and earlier, if cervical spine is involved. neurologic symptoms can manifest by any of the following process: subluxation of vertebrae, impingement of bone, disc, and abscess on the spinal cord or nerve root, local inflammatory response, and tuberculous vasculitis.1 ct scan of our patient demonstrated, spinal cord compression due to collapse of vertebra along with epidural extension of perivertebral mass, which explains the neurological deficit in our patient. spinal involvement with skip lesion has also been found in brucellosis. histopathology usually demonstrates noncaseating granulomatous tissue. spinal brucellosis may be distinguished from tuberculosis by mri also. in brucellosis, the vertebral body is usually morphologically intact despite evidence of osteomyelitis and the disc is moderately reduced in size despite evidence of involvement.8 surgical intervention in pott’s disease is indicated if there is neurologic deficit, spinal deformity with instability or pain, no response to anti-tb chemotherapy (evidenced by continuing progression of kyphosis or instability) and large paraspinal abscess.9 fig.-2: mri of cervical and upper dorsal spine showing destruction of cervical (thin black arrow) & thoracic (thick black arrow) vertebrae, with epidural abscess causing cord compression (thin white arrow), along with retropharyngeal abscess (thick white arrow). bsmmu j vol. 4, issue 2, july 2011 129 references: 1 . idris sk, abdulkadir ay. tuberculous retropharyngeal abscess with posterior mediastinal extension and quadriplegia in a 13-year-old nigerian girl. int j of pediatr otorhinolaryngol extra. 5 (2010): 118–120. 2 . al soub h. retropharyngeal abscess associated with tuberculosis of the cervical spine. tuber lungdis 1996;77: 563-565. 3 . turgut m. multifocal extensive spinal tuberculosis (pott’s disease) involving cervical, thoracic and lumbar vertebrae. br j neurosurg 2001; 15(2): 142–146. 4 . mizumura k, machino t, sato y, ooki t, hayashi k, nakagawa y et al. tuberculous retropharyngeal abscess associated with spinal tuberculosis well controlled by fine-needle aspiration and anti-tuberculous chemotherapy. inter med 2010; 49: 1155-1158. 5 . chauhan a, gupta bb. spinal tuberculosis. jiacm 2007; 8(1): 110-114. 6 . khattry n, thulkar s, das a, khan sa, bakhshi s. spinal tuberculosis mimicking malignancy: atypical imaging features. indian j paediatr 2007;74(3):297-298. 7 . shanley dj. tuberculosis of the spine: imaging features. ajr 1995;164:659-664. 8 . coskun e, süzer t, yalçin n, tahta k. spinal extradural compression caused by granuloma of brucellosis. scand j infect dis 1998;30(3):311–312. 9 . watts hg, lifeso rm. current concepts review tuberculosis of bones and joints. j bone joint surg am. 1996;78(2):288-99. multifocal extensive spinal tuberculosis with retropharyngeal abscess shumy et al 130 introduction swyer syndrome is a disorder of sex development (dsd) first described by dr swyer in 1955.1 the incidence is 1:80000.2 mutation in several different genes cause swyer syndrome or can be inherited as autosomal dominant, autosomal recessive, x-linked or ylinked manner.3 the patients with swyer syndrome have pure gonadal dysgenesis with 46 xy karyotypes. they present with female phenotype, delayed puberty, and primary amenorrhoea. they have normal looking external genitalia, vagina, hypoplastic uterus, tubes and streak dysgenetic gonads. the dysgenetic gonads may develop gonadoblastoma in 20-30 % of cases, usually bilateral, sometimes dysgerminoma and even embryonal cancer.4, 5 gonadectomy is advised as soon as the diagnosis is confirmed.6 the objective of reporting this case is to share experience with managing this rare disease as diagnosis and management is important due to chance of gonadal malignancy if not treated. case description a 16-year-old reared as girl presented with primary amenorrhoea. on examination, she was female phenotype, having a height of 165 cm, weight of 51 kg, and breasts tanner stage ii. her vulva appeared normal, with a hymenal opening, sparse axillary and pubic hair (figure 1). there was no palpable mass in the abdomen. she was her parent’s only daughter, and swyer syndrome: a rare case hema kumari pradhan1, ganesh dangal1, manoj krishna shrestha2 1department of obstetrics and gynaecology, kathmandu model hospital, kathmandu, nepal 2department of pediatric surgery, kathmandu model hospital, kathmandu, nepal correspondence to: dr. hema kumari pradhan, email: drhemapradhan@hotmail.com received: 07 may 2023; revised version received: 30 may 2023; accepted: 03 jun 2023; published online: 26 jun 2023 supplementary file, and peer review and author response: available at doi: https://doi.org/10.3329/bsmmuj.v16i2.67241 learning points 1. in primary amenorrhoea, investigation should be done if there are no secondary sexual characteristics by the age of 13 years. 2. secondary sexual characteristics appear after gonadectomy (due to risk of gonadal malignancies) and hormone replacement therapy. figure 1 local examination showing hymenal opening (left) and laparoscopic finding showing streak gonad, fallopian tube and small uterus (right) bangabandhu sheikh mujib medical university journal 2023;16(2): 128-130 bsmmu.edu.bd case report there was no such history in her family. ultrasonography reported a small uterus (2.7 cm × 0.5 cm ×0.9 cm) and non-visualization of ovaries. her hormone test reports were as follows: estradiol 5 pg/ml, leutinizing hormone 5.07miu/ml, follicle stimulating hormone 17.57 miu/ml, and testosterone 0.03ng/ml which means she had hypergonadotrophic hypogonadism. her thyroid function and prolactin were normal. she had 46xy karyotypes (figure 2), which were reconfirmed from another laboratory. no other genetic analysis could be done. her radiological age, as determined from x-rays of both wrists, was 14-16 years. finally, she was diagnosed to have swyer syndrome. case management the parents were counseled about the diagnosis being gonadal dysgenesis and there is chance of gonadoblastoma. for this she needs gonadectomy followed by hormone replacement therapy (hrt) which will be started after the operation. she can marry and have normal sexual life. for pregnancy donor egg will be required. the parents and the girl consented for operation. laparoscopy done under general anesthesia which showed hypoplastic uterus, streak gonads and fallopian tubes on both side as shown in figure 1. bilateral gonadectomy along with removal of tubes was done. histopathology revealed stroma in both gonads with no primordial follicles. after the operation, hrt was started. initially 2 mg of estradiol was given daily for 3 month and medroxyprogesterone 10 mg daily for 10 days. she had withdrawal bleeding and hrt was continued. on regular follow up, she was satisfied with withdrawal bleeding after medroxyprogestrerone. after one year of treatment, her breast size increased to tanner lll. during the covid-19 pandemic, she did not come for follow up. she informed over telephone that she stopped hrt and menstruation stopped too. after repeated counseling, she started her hrt and now is having withdrawal bleeding regularly. discussion primary amenorrhoea is defined as the absence of menses by 13 years of age in the absence of secondary sexual characteristics or by the age of 15 years in the presence of normal secondary sexual characteristics.7 swyer syndrome, a pure gonadal dysgenesis is a rare cause of primary amenorrhoea. swyer syndrome results due to mutations in genes such as arx, atrx, cbx2,dhh, dmrt1, gata4, mamld1, map3k1, nr0b1,nr5a1, sox9, wnt4, wt1, wwox, sry, and wnt4 which affects testicular differentiation and inhibit anti-mullerian hormone (amh). the sry gene is deleted in approximately 10–15%, and mutated in an additional 10–15%, of patients.8 patients with swyer syndrome are of female phenotype, tall or normal height, with insufficient pubertal development and having primary amenorrhoea. due to absence of amh the mullerian duct develops into uterus and tubes. as the xy gonads fail to develop into testes, there is no production of testosterone. as a result, they have female external genitalia with hymenal opening. hormonal test will show raised gonadotropins, decreased estrogen and normal female level androgens. our patient also had hypergonatrophic hypogonadism. the differential diagnosis are androgen insensitivity syndrome with 46xy karyotyping and true hermaphroditism. in androgen insensitivity syndrome, the breasts are well developed, have blind vagina, due to amh the internal female organs are not formed, and testosterone is in normal male level. in true hermaphroditism, ovotestes will be present. in our case, there was no ovarian and testicular tissue in the streak gonads. another common cause of primary amenorrhoea is mayer-rokitanskykuster-hauser syndrome, where the karyotype is 46xx, with well-developed female secondary sexual characteristics, and absence or rudimentary uterus or vagina.7 pradhan hk et al. bangabandhu sheikh mujib medical university journal 2023; http://doi.org/10.3329/bsmmuj.v16i2.67241 swyer syndrome 129 figure 2 karyotyping 46xy there is high risk of malignant gonadal tumour development in patients with female phenotype carrying y chromosome. in swyer syndrome, there is high chance of gonadoblastoma and dysgerminoma, so gonadectomy is advised as soon as diagnosis of swyer syndrome is established.2 after gonadectomy, hrt is started for development of secondary sexual characteristics and menstruation. they can have normal sexual life and can have baby with donor oocyte.3 the limitation of this study was lack of genetic analysis for mutant genes due to unavailability. to summarize, swyer syndrome is a rare cause of primary amenorrhoea. proper diagnosis is important as there is a high chance of gonadoblastoma, and the patient needs a gonadectomy. due to advances in assisted reproductive techniques, pregnancy is possible with donor oocytes. acknowledgments i would like to thank the patient and her parents for their cooperation. author contributions conception and designhkp. acquisition, analysis, and interpretation of datahkp. manuscript drafting and revising it criticallyhkp, gd, mks. approval of the final version of the manuscripthkp, gd, mks. guarantor accuracy and integrity of the workhkp. funding this study did not receive any funding. conflict of interest the authors have no conflict of interest to declare. ethical approval the study being a case report does not have ethical approval from the institutional review board, but the patient and her parents gave consent for the photo and reporting. orcid id hema kumari pradhan https://orcid.org/0000-0003-1508-2099 references 1. korkmaz h, özkaya m, akarsu e. swyer syndrome: a case report. turkish journal of endocrinology & metabolism. 2014; 18 (2) . doi: https://doi.org/10.4274/tjem.2365. 2. afsana f, pathan mf, shelly sj. a rare case of swyer syndrome. birdem medical journal. 2019 may 6;9(2):174-6. doi: https://doi.org/10.3329/birdem.v9i2.41289. 3. taneja j, ogutu d, ah-moye m. rare successful pregnancy in a patient with swyer syndrome. case rep women's health. 2016 oct 18;12:1-2. doi: https://doi.org/10.1016/ j.crwh.2016.10.001. 4. behtash n, karimi zarchi m. dysgerminoma in three patients with swyer syndrome. world j surg oncol 2007;5:71. doi: https://doi.org/10.1186/1477-7819-5-71 5. michala l, goswami d, creighton sm, conway gs. swyer syndrome: presentation and outcomes. bjog: an international journal of obstetrics & gynaecology. 2008 may;115(6):737-41. doi: https://doi.org/10.1111/j.14710528.2008.01703.x. 6. cherukuri s, jajoo s s, dewani d, andela m. the mysteries of primary amenorrhea: swyer syndrome. cureus. 2022 aug 19; 14(8): e28170. doi: http://dx.doi.org/10.7759/ cureus.28170. 7. baker vl, beall sa. amenorrhea chapter 34. berek and novak’s gynecology. 16thed. berek js, berek dl, editors. wolters kluwer, philadelphia, 2020; p2034-88. 8. khare j deb p, srivastava p, reddy b h. swyer syndrome: the gender swayer? alexandria journal of medicine (2017) 53:2, 197–200. doi: https://doi.org/10.1016/ j.ajme.2016.05.006. pradhan hk et al. bangabandhu sheikh mujib medical university journal 2023; http://doi.org/10.3329/bsmmuj.v16i2.67241 swyer syndrome 130 12. frequency and outcome of thrombocytopenia.ai | original | article | frequency and outcome of thrombocytopenia in neonates who are at risk of developing thrombocytopenia a prospective observational study sarbari saha, debabrata roy, ismat jahan, mohammad kamrul hassan shabuj, sadeka choudhury, ma mannan, mohammod shahidullah, sanjoy kumer dey introduction: thrombocytopenia is the commonest hematological abnormality encountered in the neonatal intensive care unit (nicu) after phlebotomy-induced anemia.1 perinatal asphyxia, prematurity/low birth weight, and sepsis are major causes of neonatal death. thrombocytopenia is a common finding in these sick neonates. if not detected early & intervention not taken, life-threatening hemorrhage can occur. a healthy neonate, even preterm, has the same mean platelet count as adults, and a platelet count less than 150,000/cmm is defined as thrombocytopenia.2 thrombocytopenia develops in 22–35% of sick newborn babies admitted to neonatal intensive care units (nicus) article info abstract department of neonatology, bsmmu, dhaka (ss, ij, mkhs, sc, mam, ms, skd); upazila health complex, kaliakoir,gazipur (dr) for correspondence: sarbari saha email: sarbari29th@gmail.com cite this ar�cle: saha s, roy d, jahan i, shabuj mkh, choudhury s, mannan ma, shahidullah m, dey sk. frequency and outcome of thrombocytopenia in neonates who are at risk of developing thrombocytopenia a prospec!ve observa!onal study. bangabandhu sheikh mujib med univ j. 2022; 15(2): 115-120. copyright: the copyright of this ar!cle is retained by the author(s) [atribu!on cc-by 4.0] available at: www.banglajol.info a journal of bangabandhu sheikh mujib medical university, dhaka, bangladesh thrombocytopenia is the commonest hematological abnormality encountered in the neonatal intensive care unit (nicu). this prospective, observational study was conducted among 78 consecutive at-risk neonates admitted in nicu, bangabandhu sheikh mujib medical university (bsmmu), dhaka from september 2016 to august 2017. platelet count was measured in all at risk neonates at enrollment and less than 1,50,000/cmm was consiered as the cut off point for determining thrombocytopenia. platelet count was measured every alternate day till discharge or normalisation of platelet count if the initial platelet count was low. if initial platelet count revealed normal, then the babies were followed up clinically if they develop any further risk condition for developing thrombocytopenia. during the period from enrollment to discharge, if any baby develops thrombocytopenia at any time then baby was defined as thrombocytopenic. overall 39.7%patients found to be thrombocytopenic among 78 at-risk neonates. pregnancy induced hypertension (pih), neonatal sepsis and small for gestational age (sga), intra uterine growth restriction(iugr), prematurity, necrotizing enterocolitis (nec) were significantly associated with thrombocytopenia. sepsis and nec were found to be independent risk factor for thrombocytopenia. regarding outcome, length of hospital stay was significantly more in thrombocytopenic patients than non-thrombocytopenic patients. death rate was also higher in thrombocytopenic patients in comparison to non-thrombocytopenic patients. received : 20 december 2021 accepted : 28 january 2022 available online : 15 may 2022 issn: 2224-7750 (online) 2074-2908 (print) doi: h"ps://doi.org/10.3329/bsmmuj.v15i2.60866 keywords: thrombocytopenia, neonate, hematological abnormality and in 50% of sick preterm.3 its incidence reaches 70% in newborn infants with birth weight <1000gm.4 thrombo cytopenia is more common in certain risk groups such as low birth weight, preterm, small for gestational age, hypoxia at birth, umbilical line placement, respiratory assistance, hyper bilirubinemia, phototherapy, respiratory distress syndrome, sepsis especially by candida infection, meconium aspiration, nec, the mother with itp and in a preterm infant with hypertensive mother. thrombocytopenia is classified as mild (100,000-<150,000/cmm of blood), moderate (50,000-<100,000/cmm) and severe (<50,000/cmm of blood).5 the risk factors for early-onset thrombocytopenia 116 bsmmu j 2022; 15(2): 115 120 are pre-eclampsia, pregnancy-induced hypertension, intrauterine growth restriction, hellp syndrome (hemolysis, elevated liver enzymes, and low platelet count), maternal diabetes & drug use.6 the most common risk factor for late-onset thrombocytopenia are sepsis and nec.7 early-onset thrombocytopenia is defined as thrombocytopenia that occurs before 72 hours of age and late-onset thrombocytopenia that occur after 72 hours of age.8 though thrombocytopenia is so prevalent it is often ignored in the surmise that it will resolve spontaneously. in most cases, neonatal thrombocytopenia is mild to moderate and can be resolved without intervention. however, life-threatening bleeding or intracranial hemorrhage (ich) with a high risk of neurodevelopment impairment may occur in severe thrombocytopenia (platelets <50 ×109/l).9 early detection and management can prevent bleeding and neurological sequelae in the thrombocytopenic neonate. the objectives of this study were to find out the frequency, hospital outcome & associated factors of thrombocytopenia in at-risk neonates. methods this observational study was carried out in nicu, department of neonatology, bsmmu, dhaka from september 2016 to august 2017. admitted inborn neonates who were at-risk for developing thrombocytopenia and out born at-risk neonates who were admitted within 24 hrs of birth in nicu, bsmmu were included in the study. a total of 78 neonates were included in the study. out born at-risk neonates who were admitted after 24 hours of birth, babies with major congenital malformation, and infants of parents who refused to give consent were excluded from the study. the at-risk newborn was defined as a newborn having any of the following criteria during enrollment or during the hospital stay i.e. positive maternal history of pregnancy-induced hypertension (pih), gestational diabetes mellitus (gdm), maternal infection, positive drug history (heparin, hydralazine, thiazide), & history of autoimmune disease (sle, itp). prematurity, low birth weight, intrauterine growth restriction (iugr) / small for gestational age (sga) babies, babies with rh-incompatibility, neonates with a history of perinatal asphyxia, neonates presenting with sepsis, and neonates who had developed features of nec. platelet count was measured in all at-risk neonates at enrollment and count less than 1,50,000/cmm was considered as the cut-off point for determining thrombocytopenia. low platelet counts were cross-verified by a peripheral smear study. if the initial platelet count revealed normal, then the babies were followed-up clinically if they develop any further risk conditions. if any risk condition developed i.e. sepsis, nec then platelet count was repeated. if the initial platelet count was low, then the platelet count was repeated every alternate day till discharge. during the period from enrollment to discharge, if any baby developed thrombocytopenia at any time then the baby was labeled as thrombocytopenic group. those who never developed thrombocytopenia were labeled as non-thrombocytopenic group. standard care was given to all enrolled neonates as per departmental protocol. treatment of thrombocytopenia consisted of transfusion of random donor platelet as per protocol. the pattern of onset of thrombocytopenia was classified as early if it developed <72 hours of birth and late if it presented after 72 hours. the severity of thrombocytopenia was graded as mild, moderate, and severe. the outcome of the enrolled neonates was assessed in terms of length of hospital stay, death, or survival. results initial platelet count was found low in 8 patients (10.2%). a total of 29 patients subsequently developed risk conditions and platelet count was measured. among them, 23 revealed thrombocytopenia, and 6 patients had normal platelet count. during the period from enrollment to discharge, total 31 patients were found thrombocytopenic. baseline demographic characteristics & maternal characteristics of thrombocytopenic and non thrombocytopenic neonates were compared. statistically significant difference was found in mean birth weight and gestational weight (p = 0.001 & 0.001 respectively). regarding gender and mode of delivery, there was no significant difference between the two groups. regarding maternal characteristics, pih was found significantly associated with the thrombo cytopenic group (p =0.02). while considering gdm and maternal infection, there was no significant difference between the two groups. (table-i) bsmmu j 2022; 15(2): 115 120 117 frequency of thrombocytopenia in at risk neonate at risk baby 78 thrombocytopenia 31 frequency 39.7% table-ii type of thrombocytopenia in at risk neonate total no of thrombocytopenic no. of percentage neonates patients (n=31) (%) early onset 8 25.8% late onset 23 74.2% table-iii comparison of baseline characteristics of thrombo cytopenic and non-thrombocytopenic neonates (n=78) characteristics thrombocytopenic non-thrombocytopenic p group(n=31) group (n=47) value gestational 32.74 ± 2.1 34.76 ± 2.3 0.001 age (weeks) birth weight (g) 1587 ± 514 2206± 698 <0.0001 mode of delivery lucs, n (%) 27 (84.3) 33(71.7) 0.08 nvd, n(%) 4(15.6) 14 (28.2) sex male, n (%) 15(48.4) 24(51.1) 0.817 female, n (%) 16(51.6) 23(48.9) pih, n (%) yes 16(51.6) 12(25.5) 0.02 no 15(48.3) 35(74.5) gdm, n (%) yes 5(16.2) 12(25.5) 0.325 no 26(83.8) 35(74.5) maternal infection, n (%) yes 8(25.8) 8( 17) 0.347 no 23(74.2) 39(83) table-i changes of visual acuity of all 3(three) patient after injection methyl prednisolone table-iv among the total of 78 patients, 31 patients were found thrombocytopenic in this study. the frequency of thrombocytopenia in the at-risk neonate in nicu, bsmmu was found approximately 39.7% (table-ii). according to severity, thrombocytopenic babies were classified as mild, moderate, and severe. mild, moderate, and severe thrombocytopenia was observed in 22.6%, 29%, and 48.4% of neonates respectively. among the 31 neonates with thrombocytopenia, 16 (51.6%) patients had frank bleeding in various forms. gi bleeding was most common (56.2%). other types of bleeding were skin bleeding (18 .7%) & bleeding through et tube (6.25%). combined skin bleeding & gi bleeding was 18.7%.(table-iv) according to the age of onset, thrombocytopenic babies were classified as early and late-onset groups. early & late-onset thrombocytopenia was 25.8% and 74.2% respectively (table-iii). grades of total no. percentage bleeding pattern of bleeding thrombocytopenia (n=31) (%) menifestation present mild 7 22.6% no no moderate 9 29% 3 gi bleeding severe 15 48.4% 13 skin bleeding(3) gi bleeding(6) combined gi and skin bleeding(3) bleeding through et tube(1) while comparing the neonatal characteristics between the thrombocytopenic group and the non thrombocytopenic group, a statistically difference was found in respect to prematurity, lbw, sga, sepsis, and nec. no statistically significant difference was found in asphyxia & rh-incompatibility. (table v) bsmmu j 2022; 15(2): 115 120118 comparison of neonatal characteristics among thrombocytopenic and non-thrombocytopenic neonates characteristics thrombocytopenic non-thrombocytopenic p group(n=31) group(n= 47) value prematurity, n (%) yes 31(100%) 34(72.3%) 0.001 no 0(0.0) 13(27.7%) lbw, n (%) yes 27(87.1) 32(68.1) 0.047 no 4(12.9) 15(31.9) sga/iugr, n (%) yes 11(35.5) 7(14.9) 0.035 no 20(64.5) 40(85.1) asphyxia, no (%) yes 7(22.5) 4(8.5) 0.08 no 24(77.4) 43(91.5) sepsis, n (%) yes 25(80.6) 18(38.3) <0.001 no 6(19.4) 29(61.7) nec, n (%) yes 6(19.4) 0(0.0) 0.002 no 25(80.6) 47(100.0) rh-incompatibility, (%) yes 1(3.2) 4(8.5) 0.351 no 30(96.7) 43(91.5) table-v outcome of enrolled infants variable thrombocytopenic non-thrombocytopenic p group (n=31) group (n= 47) value prematurity, n (%) length of <14 days 11(35.5%) 29(61.7) <0.037 hospital >14days 20(64.5) 18(38.3) stay(days) survival (no, %) 20(64.6) 43(91.4%) 0.007 death (no, %) 11(35.4%) 4(8.6%) table-vii results of multivariate regression analysis for predicting occurrence of thrombocytopenia characteristics odds ratio 95%ci p value pih 2.1 0.642-6.919 0.219 lbw 1.4 0.272-8.174 0.645 sga 0.451 0.111-1.83 0.266 sepsis 4.3 1.3-14.05 0.02 table-vi statistical test: chi square test, p-value is significant <0.05 multivariate regression analysis was done for predicting the association with thrombocytopenia. only sepsis was found to be an independent risk factor for developing thrombocytopenia. (table vi) discussion in this observational study, the frequency of thrombocytopenia in at risk neonates was found to be 39.7%. in previous studies conducted in sri lanka and india, prevalence rate documented were 55% and 63% respectively10,11 which is much higher than this study. variable prevalence rates were documented in different studies most probably because of wide variations in case inclusion, sample size and geographic variation. regarding demographic characteristics, mean birth weight was significantly lower in thrombocytopenia group in comparison to non-thrombocytopenia group. study conducted in tehran by khalessi n and colleagues also showed similar result.12 mean gestational age in this study was also lower in thrombocytopenia group in comparison to non-thrombocytopenia group. the result is consistent with another study which show the mean gestational age at birth among thrombocytopenic neonates was 32.2±2.5 weeks which was less than the average gestational age at birth among all neonates (p=0.0001).12 no statistically significant difference in gender was observed between neonates with and without thrombocytopenia in this study. regarding mode of delivery, no significant difference was observed also between two groups in this study. regarding maternal characteristics, pregnancy induced hypertension was found significantly associated with thrombocytopenia. (51.6% in thrombocytopenic group and 25.5% in non-thrombocytopenic group). the other two factors gdm and maternal infection were not found statistically significant. regarding neonatal characteristics, prematurity was significantly associated with thrombocytopenia. among 84% of preterm baby, 47.6% had regarding outcome, the number of patients who stayed more than 14 days in hospital was significantly higher in the thrombocytopenia group in comparison to the non thrombocytopenia group. the mortality rate was also higher in the thrombocytopenia group than nonthrombocytopenia (35.4% vs 8.6%, p value-0.007). (table vii) bsmmu j 2022; 15(2): 115 120 119 thrombocytopenia. no full term babies had thrombocytopenia. this may be due to the small sample size in this study. prematurity is a risk factor for thrombocytopenia due to decreased platelet production and when this was associated with sepsis, the increased consumption of platelets further contributes to severe thrombocytopenia. lbw was significantly associated with thrombocytopenia in this study (p=.047). charoo ba and colleagues also stated that neonatal thrombocytopenia was more common among low birth weight babies.13 however, sharma et al showed low birth weight was not significantly associated with thrombocytopenia (p=0.47).10 gupta and colleagues stated that lbw babies showed statistically significant thrombocytopenia due to their limited ability to compensate for accelerated destruction of platelets. placental transport of igg from maternal to fetal circulation increases with maturity and this transport is hampered in low birth weight babies which make them more prone for sepsis.14 in this study, sepsis was significantly associated with thrombocytopenia (p=<0.001).14 gupta et al observed that 81.5% of septic neonates developed low platelet counts. in studies conducted by patil et al & zaccheaus et al, sepsis was associated with severe thrombocytopenia with results similar to the current study.15,16 among the septic neonates, 25% had positive blood culture. organisms isolated from the blood of septic babies in order of frequency were: klebsiella, acinetobacter & pseudomonas. klebsiella was the most commonly isolated organism observed in study by arif sh et al.17 septicemia leads to thrombocytopenia due to both decreased production and increased consumption of platelets and hence results usually in severe thrombocytopenia. sepsis also causes dic, immune-mediated destruction and decreased production of platelets from infected marrow. in this study, sga was significantly associated with thrombocytopenia (p=0.035). maruyama h et al found growth restriction to be a significantly independent risk factor for thrombocytopenia which is consistent with our study.18 in our study, total 5 patient had nec and all of them had thrombocytopenia. in contrast to the current study, sharma et al showed nec was not significantly associated with thrombocytopenia (p=0.058).10 in this study, perinatal asphyxia was not significantly associated with thrombocytopenia (p=0.08). however, relationship between the severity of thrombocytopenia and the severity and staging of hypoxic ischemic encephalopathy was demonstrated in study conducted by nursen et al.19 thrombocytopenia in hie may be due to increased platelet destruction as mean platelet value was raised. in multivariate regression analysis, only sepsis and nec were found to be independent risk factor for developing thrombocytopenia. bonifacio l and colleagues observed that mucocutaneous bleeding complicated 18.4% of cases with severe and late-onset thrombocytopenia.20 in this study 16 (51.6%) of at risk neonates with thrombocytopenia developed bleeding. von lindern et al showed that out of all included neonates with thrombocytopenia, 29% received a platelet transfusion.21 in this study 18 (58%) high risk neonates with thrombocytopenia received platelet transfusions. regarding outcome, among 31 thrombocytopenic neonates, 11 died. mortality rate was 35.4% compared to 8.6% in non-thrombocytopenic neonates. previous study done by bonifacio l et al also demonstrated that mortality rate among the non-thrombocytopenic neonates was 1.4% as compared to 16.7%, 32.4%, and 45.8% in preterm neonates with mild, moderate and severe thrombocytopenia respectively.20 in another study done by sola mc et al, incidence of mortality was found to be 34% in preterm neonates.22 conclusion frequency of thrombocytopenia in at risk neonate in nicu, bsmmu was approximately 39.7%. prematurity, lbw, pih, sepsis and sga/iugr, nec were significantly associated with thrombocytopenia. duration of hospital stay and mortality rate were higher in thrombocytopenic neonates than nonthrombo cytopenic neonates and survival rate was higher in non-thrombocytopenic neonates than thrombo cytopenic neonates among at risk neonates. as the prevalence of neonatal thrombocytopenia is high, it is important to look for platelet count, severity, degree and pattern of onset of thrombocytopenia in each and every case of at risk neonates admitted to nicu, which will help the clinician in diagnosis, planning investigations and aid in appropriate management & improve outcome. a large sample, multicenter study should be conducted to support the current study bsmmu j 2022; 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