Akansha Agrawal

Patients on dialysis have an increased incidence of tuberculosis (TB). Rifampicin, a first-line antitubercular therapy (ATT) drug, is a potent inducer of hepatic cytochrome P450 (CYP). There is potential for pharmacokinetic interaction between rifampicin and anti-hypertensives that are CYP substrates: amlodipine and metoprolol. Therefore, hypertensive patients receiving rifampicin-based ATT are at risk for worsening of hypertension. However, this hypothesis has not yet been systematically studied. In this prospective study, hypertensive CKD 5D patients with TB were followed after rifampicin initiation. Blood pressure (BP) was ≤140/90 mmHg with stable anti-HT requirement at inclusion. Serum amlodipine, metoprolol, and prazosin levels were estimated by high-performance liquid chromatography at baseline and 3, 7, 10, and 14 days after rifampicin initiation. BP and anti-HT requirement were monitored for 2 weeks or until stabilization. All 24 patients in the study had worsening of hypertension after rifampicin and 83.3% required increase in drugs to maintain BP 50% in all patients and became undetectable in 50-75%. Drug requirement increased from 4.5 ± 3.6 to 8.5 ± 6.4 units (P < 0.0001). Mean time to first increase in dose was 6.5 ± 3.6 days. Eleven (46%) patients experienced a hypertensive crisis at 9.1 ± 3.8 days. Three of them had a hypertensive emergency with acute pulmonary edema. In two patients, rifampicin had to be discontinued to achieve BP control. In conclusion, rifampicin caused a significant decrease in blood levels of commonly used anti hypertensives. This decrease in levels correlated well with worsening of hypertension. Thus, we suggest very close BP monitoring in CKD patients after rifampicin initiation.

Background: Weakness and fatigue are accepted as normal accompaniments of aging. Usually, older individuals are not investigated with much enthusiasm but a treatable cause is discernible on several occasions. Case presentation: We had a 67 year old hypertensive lady with a mitral stenosis, presenting in ischemic or hypertensive heart failure with underlying valvular disease, without pulmonary hypertension in sinus rhythm. She had pancytopenia with severe anemia and raised liver enzymes. Bone marrow examination showed aplastic anemia. She was treated with ATG and improved subsequently to become transfusion free. However, she succumbed to an unrelated sudden cardiac death. Conclusion: Our patient is unique in her uncommon presentation, complex management issues and a favorable outcome after a long and persevering therapeutic intervention and finally her sudden death.

Introduction: Mesotheliomas are rare tumours that usually are seen in the pleura after asbestos exposure. Mesotheliomas have been reported around the testicular region but are even rarer following trauma, herniorrhaphy and long term hydrocoele. Case presentation: An elderly male farmer presented to us with an insidious onset of painless swelling in his left lower limb which gradually progressive. At the time of presentation it had involved his entire limb. A hard palpable mass of size 5 * 4 cms was detected in the left iliac fossa and a testicular enlargement was noted on the left side. The ultrasound of the testes showed that the left testis was enlarged 3.9*3*3.2 cms showing diffusely heterogenous echo-texture and irregular nodular surface with irregular hypoechoic thickening of the scrotal wall with left sided hydrocele. A separate hypoechoic *1.2 cms lesion was visualized in the anterior scrotal wall. FNAC from the scrotal mass showed tumour cells of simialr morphology present singly in monolayered sheets and in three dimensional fragments. The overall immunomorphological features suggested a malignant mesothelioma likely to have arisen from the tunica vaginalis. Conclusion: In conclusion, though a rare tumor, malignant mesothelioma of the tunica vaginalis of the testis should be considered whenever a paratesticular mass lesion is seen even without a history of trauma or asbestos exposure as is highlighted in this case. Ultrasound findings are helpful and fine needle aspiration of the tumor may assist in arrival at a diagnosis. Surgical orchidectomy remains the modality of treatment.