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Histoplasmosis has been sporadically reported from India. Though asymptomatic adrenal involvement has been described in patients with disseminated histoplasmosis; isolated adrenal involvement with adrenal insufficiency (AI) as the presenting manifestation of the disease is rare.We describe 5 immunocompetent men (mean age 55.6 yrs) from a nonendemic area with adrenal histoplasmosis presenting with constitutional symptoms. Three patients had AI at presentation with bilateral adrenal involvement and the other two developed AI during the course of the illness and had unilateral adrenal mass . All the patients had histopathological/cytologically proven adrenal histoplasmosis. 18FDG-PET done in 3 patients helped in delineating the extent of the disease. Adrenalectomy was done in 2 patients who presented with unilateral adrenal mass. All these patients received Amphotericin B and/or itraconazole treatment which led to symptomatic improvement but AI persisted in all at the end of the follow up of 6 to 18 months.The diagnosis of adrenal histoplasmosis should be considered in patients presenting with constitutional symptoms and unilateral or bilateral adrenal mass/es with or without AI.

To determine the frequency of adrenal, thyroid and gonadal dysfunction in HIV positive male patients and to evaluate the endocrine function at different level of CD4 cell counts.A total of 150 male HIV positive subjects were included in study. The patients were divided in three groups on the basis of CD4 cell counts. "Group A": HIV positive with CD4 count200/mm "Group B": HIV positive with CD4 count 200-350/mm3 and "Group C": HIV positive with CD4 count350/mm3.In "group A" (n=50) 2 patients had basal cortisol5 microg/dl while 23 patients had basal cortisol25 microg/ dl. 15 patients had subclinical hypothyroidism while 11 patients had overt hypothyroidism. 25 patients in this group had gonadal dysfunction: majority of them (24) had primary gonadal dysfunction (elevated LH). None of the patients in "group B" (n=50) had hypocortisolism while 11 patients had elevated cortisol; 18 had subclinical hypothyroidism while 4 had overt hypothyroidism while 17 patients were hypogonad, all having elevated LH. In "group C" (n=50) 2 patients had hypocortisolism and 5 had elevated cortisol; 12 patients had subclinical and one had overt hypothyroidism; 7 patients had primary hypogonadism and one had secondary hypogonadism. Overall 4(2.66%) had hypocortisolism while 39 (26%) had elevated cortisol; 45 (30%) had subclinical hypothyroidism while 16(10.66%) had overt hypothyroidism. Gonadal dysfunction was observed in 50 patients (33%) majority of them (48) had primary hypogonadism. On analysis of Pearson's correlation coefficient CD4 count has strong inverse correlation with basal cortisol (r=-0.301, p0.0001), TSH (r=-0.257, p=0.002) and LH (r=-0.228, p=0.006), while there was a direct correlation with serum testosterone (r=0.175, p=0.037).This pilot study has demonstrated a high incidence of endocrine dysfunction in HIV infected patient in this part of country. High incidence of thyroid and gonadal dysfunction may contribute to morbidity of the patients and have a bearing on quality of life of the HIV infected patients. Hypocortisolism was not that common but high level of cortisol may be a marker of stress due to HIV per se or due to associated infection. Many of these dysfunctions might be transient and a large longitudinal study should be undertaken to substantiate the finding of the present study.

To determine the efficacy of simple needle aspiration in the management of primary spontaneous pneumothorax. Not all patients with pneumothorax require intercostal tube drainage (ICTD). Some patients can be managed conservatively by simple needle aspiration of air from pleural space. It is a cheap and easy alternative to ICTD which can be done on out patient basis.All patients of spontaneous pneumothorax presenting for the first time were included in this study, after obtaining baseline investigations like chest X-ray, ECG, serum creatinine, blood sugar etc. They were managed by ICTD or simple needle aspiration. Chest X-ray was done 6 hours after the procedure (ICTD), 24 hours after aspiration and prior to ICTD removal or before hospital discharge. Patients who had undergone simple needle aspiration were allowed to go home following a few hours of observation after explaining the warning symptoms and the need for reevaluation after 24 hrs, if prompt follow-up could be ensured otherwise they were admitted along with patients undergoing ICTD.Eighty two patients of spontaneous pneumothorax were included in this study during a-period of 12 months (May- 04 to April - 05). Out of these 40 (49%) patients were managed by ICTD, 42 (51%) patients were subjected to simple needle aspiration. Thirty two (76%) patients responded to simple needle aspiration while the remaining 10 patients required ICTD finally. There were no complications in the patients managed by simple needle aspiration; they had less chest pain and lesser duration of hospital stay.Spontaneous pneumothorax may be managed by simple needle air aspiration primarily, unless contraindicated (tension pneumothorax), or in patients requiring mechanical ventilation. For symptomatic patient it is the recommended procedure.

Androgen deprivation therapy is the first-line systemic treatment of prostate cancer, orchidectomy remaining the most common mode in view of cost-effectiveness and better compliance. Accelerated bone loss is common after orchidectomy, which exacerbates osteoporosis already common in this patient-population. We studied the need of periodic measurement of bone mineral density after orchidectomy.Fifty five patients of adenocarcinoma prostate opting for orchidectomy were prospectively studied. Follow up ranged from 6 to 18 months. Lumbar spinal (L1-L3) trabecular bone mineral density (BMD) was measured with quantitative computed tomography (QCT) at baseline and every 6 months after orchidectomy, and compared with preoperative values.Mean (+/- SD) age of the patients was 69.9 +/- 7.9 years and BMD 115.7 +/- 35.7 mg/cm2 with T-score -1.89 +/- 1.26 and Z-score 0.30 +/- 1.30. Thirty three percent patients were osteoporotic at baseline, as defined by a T-score-- 2.5. Fall of BMD six months after orchidectomy was statistically significant (12.1%, p = 0.0001) increasing the proportion of osteoporotics to 49%. Twenty four patients completing 12 months follow up, were separately analyzed and showed similar fall in BMD in first 6 months of follow up (13%) and further 8% loss in next six months. Ten patients were followed up for 18 months, and these did not show significant loss of BMD beyond 12 months (p = 0.9).Osteoporosis is common in hormone-naive population affected by prostate cancer and orchidectomy leads to accelerated exacerbation of this bone loss. Periodic measurement of BMD using QCT after ADT would help in early detection of osteoporosis.

Both diabetic nephropathy (DN) and nondiabetic nephropathy (NDN) are reported to occur in patients with type 2 diabetes mellitus (DM). The precise diagnosis of the type of nephropathy has obvious clinical and prognostic implication. The aim of the study was to evaluate the histologic spectrum of nephropathy in proteinuric type 2 diabetic patients and to find the correlation between type of nephropathy and diabetic retinopathy (DR).Twenty eight proteinuric type 2 diabetic patients were included in the study. Five patients (ADPKD 3 and chronic pyelonephritis 2) were excluded from biopsy. Percutaneous renal biopsy was carried in remaining 23 patients.There was a preponderance of male (75%) and majority of the patients were in the age group of 30-78 years. Duration of diabetes ranged between 4 months to 25 years with mean +/- SD of 10.53 +/- 7.62 years. The presenting features were nephrotic syndrome 14 (60.9%), non-nephrotic proteinuria 9 (39.1%) and impaired renal function in 19 (82.6%) patients. Renal biopsy in 23 cases revealed; isolated diabetic nephropathy 13 (56.2%), NDN7 (13.43%) and 3 (13%) patients had NDN superimposed on diabetic nephropathy. Membranous nephropathy (2), focal segmental glomerulosclerosis (2), mesangiocapillary glomerulonephritis (1) were the nondiabetic glomerular disease in our type 2 diabetic patients. Chronic pyelonephritis and ischemic interstial nephropathy was the predominant tubulointerstial lesion in this study. Diabetic retinopathy (DR) observed in 12 (75%) patients with biopsy proven DN and absent in 4 (25%) patients with DN. The distribution of renal lesions in patients with DR (n = 15) showed DN in 9 (60%), NDN 3 (20%) and remaining 3 patients had combined lesions. Renal biopsy in 8 patients without DR showed typical DN in 4 (50%) and NDN in 4 (50%) patients.This study demonstrates presence of both glomerular and tubulointerstitial lesions unrelated to diabetes (NDN) in proteinuric type 2 diabetic patients. Further presence or absence of DR was a poor predictor of diabetic nephropathy because DN was noted in 50% of patients without DR and 40% of patients with DR had non-diabetic nephropathy either alone or in combination with DN.

Polyglandular autoimmunity (PGA) type 2 presenting in childhood is extremely rare. We report a case of type 2 PGA who had hypothyroidism, followed by diabetic ketoacidosis and was later diagnosed to have adrenal insufficiency also.

The etiology of slipped capital femoral epiphysis (SCFE) is unknown, though hormonal as well as mechanical factors have been implicated. We report a case of gigantism who presented with SCFE. This case provides an insight into the genesis of SCFE, which in this case was related to growth hormone excess and sex-hormone deficiency.

Hyperthyroidism is seen in 3.5-26% of acromegalic subjects, and can occur through TSH-dependent or independent mechanisms. Thyrotoxicosis as the first presenting illness in acromegaly is particularly uncommon, as described in this patient who had both acromegaly and a toxic thyroid adenoma.

The best method for glucose lowering in lean type 2 diabetes remains controversial and this study was undertaken to study the 24 hour insulin response of these diabetics to glimepiride, a sulfonylurea with distinctive properties.Twenty five consecutive newly diagnosed diet-unresponsive lean type 2 diabetics (BMI19 kg/m2) without any vascular complications were given single dose (1 mg) of glimepiride and insulin responses were measured 2,4,8,12 and 24 hours later. Pre and post-glimepiride blood glucose levels were also measured.All the post-glimepiride insulin levels were significantly higher than basal values. Increase in insulin secretion peaked at four hours and benefits lasted for at least 24 hours. This was accompanied by clinically and statistically significant reductions in fasting and postprandial blood glucose levels. Maximum secretory response correlated positively with beta cell function (HOMA) and negatively with fasting glucose.Glimepiride improved insulin secretion and hyperglycemia in lean type 2 diabetic subjects, with benefits lasting for 24 hours. The degree of response was proportional to the beta cell reserve, and occurred irrespective of the presence or absence of markers of insulin resistance.

We compared the clinical and biochemical profiles of young diabetics in North Eastern India.Seventy diabetics who were detected at less than 30 years of age were studied. Patients with ketoacidosis or ketonuria on insulin withdrawal were grouped as insulin dependent diabetes mellitus (IDDM), patients with history of chronic abdominal pain with or without exocrine pancreatic dysfunction who either on ultrasonography (USG) or endoscopic retrograde cholangiopancreaticoduodenography (ERCP) revealed pancreatic calcification and/or ductal dilatation were grouped as fibrocalculous pancreatic diabetes (FCPD), those having BMI19 kg/m2 with history or stigmata of childhood malnutrition and who were ketosis resistant were taken to be protein deficient diabetes mellitus (PDDM)/malnutrition modulated diabetes mellitus (MMDM) and those who neither had ketonuria nor history of chronic abdominal pain, malabsorption or stigmata of malnutrition were grouped as NIDDM of young (NIDDY).Amongst the young diabetics studied FCPD constituted 32.9%, IDDM 28.6%, MMDM 21.4% and NIDDY 17.11%. USG abnormalities were observed in 21 of the 23 patients of FCPD. Seven out of these showed pancreatic head calcification on X-ray while 14 showed pancreatic duct dilatation and calcification or calculi on USG. In the two remaining patients, ERCP revealed tortuousity of main pancreatic duct and calcification which were not detected on USG. Majority of FCPD and MMDM patients revealed insulin resistance on insulin tolerance test (ITT). HDL was significantly lower in NIDDY, while VLDL and triglycerides were significantly higher in FCPD and MMDM as compared to controls. Microvascular complications of diabetes were seen in all these groups, with peripheral neuropathy being more common in FCPD (43.5%) and background diabetic retinopathy in NIDDY (41%).We conclude that FCPD and MMDM together form majority (54.29%) of young diabetics at our center and a sizeable proportion of them may have microvascular complications, even at the time of diagnosis.

Relationship between microalbuminuria and diabetic retinopathy in patients with type 1 and type 2 diabetes mellitus has been described. Patients with lean type 2 diabetes mellitus has some difference of insulin secretion and action in comparison with obese type 2 diabetes mellitus and there are evidences to support that lean type 2 diabetes mellitus is slow emerging type 1 diabetes mellitus in our population. The aim of this study is to find out correlation between retinopathy and microalbuminuria in lean type 2 diabetes mellitus.Fifty two patients with lean type 2 diabetes mellitus (BMI18.5 Kg/M2) were selected. Diabetic retinopathy was observed in 25 patients only. Blood glucose sample was taken after 10 hours of overnight fasting. Glycosylated haemoglobin (HbA1c) was measured by calorimetric method and urinary albumin was estimated in morning urine saniple by Micral II test strip.Patients with diabetic retinopathy had longer duration of diabetes detected than those with normal fundus but the difference was statistically insignificant. Fasting blood glucose greater than 200 mg/dl was found in 63.6% of patients with diabetic retinopathy and in 36.4% of patients with normal fundus but the difference was insiginificant. Patients with diabetic retinopathy had microalbuminuria test positive and level was significantly higher in patients with proliferative retinopathy than in patients with background retinopathy.Microalbuminuria is associated with diabetic retinopathy in lean type 2 diabetes mellitus. Increase in urinary albumin excretion correlates with development of proliferative diabetic retinopathy in lean type 2 diabetes mellitus similar to type 1 and type 2 diabetes niellitus. This study emphasizes that microalbuminuria estimated by semi quantitative method is a cost effective and reliable marker of diabetic retinopathy in lean type 2 diabetes mellitus and high level of this may serve as an indicator of proliferative retinopathy in them.

Robinow syndrome is a rare congenital abnormality. It is characterized by mesomelic brachymelia, hemivertebrae, dysmorphic facies, genital hypoplasia, micropenis, clinodactyly, camptodactly, hypoplastic nails and moderate short stature. We are documenting the case on the account of its rarity and additional features.

Hyperinsulinemia has been implicated in the pathogenesis of hypertension both in non-diabetic and diabetic patients. A causal relationship between renal sodium retention and hyperinsulinemia is speculated to play role in the development of hypertension in diabetes mellitus.Twenty patients (12 males; 8 females) with hypertension and non-insulin dependent diabetes mellitus (NIDDM) and twenty normotensive patients (11 males, 9 females) with NIDDM were included in the present study. Blood samples for glucose and immunoreactive insulin (IRI) assay were collected at 0, 30, 60 and 120 minutes after 75 g of glucose per oral. Urinary sodium excretion in 24 hrs was estimated by flame photometry. Insulin response to glucose and correlation between basal insulin secretion and urinary sodium excretion were evaluated.Mean fasting plasma glucose value was significantly raised in hypertensive group in comparison with normotensive group of diabetic patients. Patients with diabetes and hypertension and significantly higher level of serum IRI than normotensive patients with diabetes mellitus. Urinary sodium excretion was significantly lower in diabetic patients with hypertension than in diabetic patients without hypertension. A negative correlation between basal insulin level and urinary Na+ excretion was observed in hypertensive patients with NIDDM.A negative correlation between hyperinsulinemia and 24 hrs urinary Na+ excretion was observed in patients with diabetes and hypertension. The study highlights that patients with diabetes mellitus have tendency to retain sodium under the influence of insulin but this needs further evaluation.

Theophylline pharmacokinetics before and after rifampicin administration was studied in 10 healthy volunteers. It was seen that Rifampicin significantly increased the volume of distribution of theophylline by 23.41% (p0.01) and its metabolic clearance by 47.65% (P0.05). This has got clinical significance in the treatment of patients of pulmonary tuberculosis with chronic obstructive airways disease where both the drugs may have to be given concurrently.

Homocystinurias are a relatively rare group of seven distinct genetic disorders of amino acid metabolism characterised by increased concentration of sulphur containing amino acid homocysteine in the blood and urine. Its transmission is believed to be autosomal recessive. We reported a family with four females siblings spared and three male siblings affected. This case is reported because of its rarity and peculiar genetic transmission.

We present a patient with pyoderma gangrenosum, a rare complication of ulcerative colitis. The patient's disease was limited to the distal colon, was clinically mild and responded quickly to treatment, and yet it was associated with pyoderma gangrenosum and arthritis, complications generally associated with more severe and extensive ulcerative colitis.

Colonoscopic snare polypectomy was carried out in 70 patients (40 children, 30 adults). There was a male preponderance in both the groups with a combined male: female ratio of 4.4:1. The majority of patients (85%) were aged 20 years or below. All patients presented with intermittent bleeding per rectum, ranging from 2 months - 6 years (mean 1.2 +/- 1.1 years) in children and 1-14 years (1.9 +/- 2.3) in adults. The majority of patients polyps were located in the rectum (73%) or in the rectosigmoid region (21%). Polyps were significantly more common in the rectum (80% vs 63%; P less than 0.01) and less frequent in the rectosigmoid (15% vs 30%; p less than 0.01) in children as compared to adults. A single polyp was present in 49 (70%) patients; 17 (24%) had 2-10 polyps, while 4 patients (2 children, 2 adults) had more than ten polyps. Most patients (94%) had polyps of less than 2 cm size. Histologically, the most polyps (91.5%) were of the juvenile variety; 39 (97.5%) children and 25 (83%) adults had this variety of polyp. The remaining 5 (17%) adults and one (2.5%) child had adenomatous polyps. The difference in the polyp histology between the two age groups was statistically significant (p less than 0.05). Only one patient (1.4%) had excessive bleeding following polypectomy. The present study suggests two important differences in the nature of polyps as compared to the West: 1) our patients were much younger, and polyps were rare after 40 years; and (2) histologically, the commonest polyps were of the juvenile variety (91.5%) while adenomatous polyps were rare (8.5%).