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Objective: To find out the differences in disease severity of Rheumatoid Arthritis (RA) depending on clinic-demographic variables and determine association between clinic-demographic variables and disease severity of RA. Study Design: Cross-sectional Analytical study. Setting: Department of Medicine & Allied at CMA Hospital, Azra Naheed Medical College, Superior University Lahore. Period: August 2021 to April 2022. Material & Methods: After IRB approval 266 patients, aged 21 to 80 years, of both sexes, diagnosed with RA were enrolled. DAS-28 score was employed to assess disease severity. Demographic information and medical records of the patients were assessed and recorded. SPSS version 21 was used for data analysis. Results: Among the 133 patients with active disease, 113 (85.0%) were females and 20 (15.0%) male having mean age 40.0+12.8 years. Mean duration of disease in years was 8.3+6.2 and mean DAS-28 score was 5.5+0.9. RA Factor was positive in 96 (72.2%) and Anti-CCP antibody was seen in 78 (58.8%). Mean Hemoglobin level was 11.7+1.1 g/dl and anemia was found in 47 (35.5%) patients. Mean TLC and platelet count were 8.8+2.2 ×109/L and 375.9+83.5 ×109/L respectively. Among the 133 patients with LDA/remission, 106 (79.7%) were females and 27 (20.3%) male having mean age 44.5+15.5 years. Mean duration of disease in years was 8.5+7.6 and Mean DAS-28 score was 2.5+0.5. RA Factor was positive in 106 (79.7%) and Anti-CCP antibody was seen in 94 (70.7%). Mean Hemoglobin level was 12.6+1.8 g/dl and anemia was found in 29 (21.8%) patients. Mean TLC and platelet count were 9.5+3.5 ×109/L and 333.7+109.1 ×109/L respectively. Conclusion: Anti-CCP antibody positive patients with anemja and having disease for more than 3 years are more likely to have active rheumatoid arthritis whereas there was no significant difference with regards to age, sex and RA Factor status.

Objective: To determine the frequency of hypothyroidism in patients with pulmonary hypertension. Study Design: Observational Cross-sectional study. Setting: Department of Medicine, Sandeman Provincial Hospital, Bolan University of Medical & Health Sciences Quetta Pakistan. Period: March 2020 to March 2021. Material & Methods: Pulmonary Hypertension was defined as mPASP of >25 mm Hg at rest on transthoracic echocardiogram and hypothyroidism was labeled when TSH was high with low Free T4 and/or Free T3. Patients with congestive cardiac failure, pulmonary malignancy or pulmonary metastasis assessed by history and examination were excluded from the study. Using non-probability consecutive sampling, 186 patients of both genders, aged 20-65 years with pulmonary hypertension were included. Demographic information along with clinical variables noted, echocardiography was done and thyroid profile was sent for each patient. Results: Mean age was 41.2+11.2 years with 56 (30.1%) males and 130 (69.9%) females. The mean height, weight and BMI were 1.6+0.2 meters, 56.5+14.4 kilograms and 21.8+3.6 kg/m2 respectively. The mean mPASP was 40.2+7.1 mmHg. The mean serum TSH, free T3 and free T4 levels were 6.6+4.8 IU/L, 2.5+1.0 pmol/L and 1.1+0.4 pmol/L respectively. In our study, hypothyroidism was seen in 46 (24.7%) and was not significantly associated with age, gender, BMI or mPASP. Conclusion: Hypothyroidism was noted in about a quarter of the patients with pulmonary hypertension in this study.

Objective: Acanthosis Nigricans is characterized by skin thickening with hyperpigmentation dermatosis predominantly seen on flexural aspects & nape of neck. The objective of present study was to determine frequency of Acanthosis Nigricans among patients of type II diabetes mellitus. Study Design and Setting: This observational cross-sectional study was undertaken at Department of Medicine Azra Naheed Medical College, Superior University Lahore from August 2021 to April 2022. Methodology: Type II diabetes mellitus was defined as patients with HbA1c 7.0%, or two blood glucose random readings of =200mg/dl, or previous history of diabetes diagnosis, or taking anti-hyperglycemic medicines. Acanthosis Nigricans was defined as >2 cm poorly defined hyperpigmented skin lesions of brownish black color and velvety appearance present over the nape of neck, axillae and/or groin. Patients with non-diabetic causes of Acanthosis Nigricans were excluded. After informed consent, 340 patients of type II diabetes mellitus aged 30-75 years of both gender were enrolled using nonprobability consecutive sampling technique. Demographic information was noted and the patients were examined for Acanthosis Nigricans. Data was entered and analyzed by SPSS version 20.0. Results: Mean age was 48.2+13.8 years with 187 (55.0%) females. The mean height, weight and BMI were 1.5+0.3 meters, 57.8+11.6 kilograms and 28.8+9.5 kg/m2 respectively. The mean duration of disease was 44.2+9.3 months and Acanthosis Nigricans was seen in 86 (25.2%). Acanthosis Nigricans was not significantly associated with age, gender, BMI or duration of disease. Conclusion: Acanthosis Nigricans was present in almost a quarter of type II diabetes mellitus patients.

We present the case of a 27 year old woman who presented with paralysis of left-half of the body and inability to speak for 1 day. She was a diagnosed patient of Rheumatic heart disease since her childhood for which mitral valve replacement with metallic valves had been done 7 years ago. She had been taking warfarin regularly but INR had not been monitored. She had one child born through Cesarean section at 37 weeks of gestation 4 weeks prior to presentation. She had taken warfarin throughout her pregnancy, and discontinued it 2 days before her delivery. Her CT brain showed multiple bilateral asymmetrical hemorrhagic venous infarcts due to sinus thrombosis subsequently confirmed by Magnetic Resonance Venography. The final diagnosis was Rheumatic heart disease with hemorrhagic venous infarcts due to cortical venous thrombosis and a multidisciplinary management involving radiologist, cardiologist, neurologist and gynecologist was planned.

Objective: To find out the frequency of hiatal hernia among patients with dyspepsia undergoing esophagogastroscopy. Study Design: Descriptive, Cross-sectional study. Setting: Departments of Medicine and Gastroenterology, Services Hospital Lahore. Period: December 2018 to June 2019. Material & Methods: A total of 195 patients with dyspepsia aged 20 to 60 years of both sexes were enrolled. Patients with history of gastric or duodenal ulcer, pregnant women, Chronic Renal Failure and Chronic Liver Disease were excluded. After taking informed consent, esophagogastroscopy was done in each patient and presence or absence of hiatal hernia was noted. Results: Out of 195 patients enrolled 104 (53.3%) were male. Mean age was 41.3±8.8 years and mean duration of disease 6.3±2.0 months. Mean BMI was 27.5±3.0 kg/m2 and 101 (51.7%) had BMI

Objective and background: Previous studies have reported a high prevalence of depressive and anxiety disorders in medical students. The aim of the current study was to investigate the prevalence of PTSD symptoms among 1st to 3rd year MBBS students. Place and duration: The study was conducted at Azra Naheed Medical College, Superior University, Lahore, Pakistan from 15th of August o 15th of September 2022. Methodology: A Google form was developed by authors of the study that comprised demographic questions as well as items of post-traumatic stress disorder checklist-Civilian version (PCL-C). The form was posted in the official WhatsApp group of each class and the rationale and purpose of the study were communicated to students. Confidentiality of the data was ensured and anonymity of the participants maintained at all stages. The study was formally approved by the Institutional review board of Azra Naheed Medical College, Lahore. Descriptive statistics, independent samples T-test and the ANOVA test were employed to analyze and report the findings. SPSS version 26 was used for reporting and analyzing the data. Results: A total of 223 medical students (45.4% males) participated in the study. Nearly three quarters of medical students (73.4%) had either moderate, (29.1%) or severe (44.3%) PTSD symptoms. No significant difference was found between the students with regards to gender, age group and year of study. Students who belonged to a mixed rural/urban background had significantly higher PTSD symptoms as compared to students from a predominantly rural or urban background. Practical Implication Medical students should be routinely assessed for the presence of anxiety/depressive disorders, as successful treatment of these disorders may improve the quality of life as well as the academic performance of the students. Conclusions: The prevalence of PTSD symptoms in medical students participating in this study is very high. Future studies should investigate the reasons as well as the risk factors associated with PTSD in medical students. Keywords: Post Traumatic stress disorder, Medical students, Anxiety

Aim: To determine the frequency of recurrence of hepatic encephalopathy in patients treated with Rifaximin. Study design: Observational cross-sectional study. Setting & duration: Department of Medicine, Services institute of Medical Sciences Lahore for duration of 12 months. Methodology: Hepatic encephalopathy was diagnosed using West-Haven classification in patients of chronic liver disease. Recurrence was considered if a new episode of hepatic encephalopathy occurred within 3 months after initiation of treatment. A total 120 patients of chronic liver disease having had an episode of recent hepatic encephalopathy within the last 3 months, of both genders, above 20 years of age with hepatic encephalopathy were included in the study. The patients were followed for 3 months after initiation of therapy and any episode of recurrence of hepatic encephalopathy was recorded. Results: Mean age was 51.5±12.2 years and 52.3±12.8 years respectively in Rifaximin and Placebo groups. Fourteen (23.3%) patients in Rifaximin group and 17(28.3%) in placebo group were younger than 40 years of age. Thirty-three (55%) patients in Rifaximin group were male versus 29(48.3%) patients in Placebo group. Fifteen (25%) patients in Rifaximin Group developed hepatic encephalopathy by 3 months of follow up as compared to 31(51.7%) patients in Placebo Group Conclusion: Frequency of recurrence of hepatic encephalopathy is significantly lower in Rifaximin treated patients. Keywords: Hepatic Encephalopathy, Recurrence, Rifaximin.

Granulomatosis with polyangiitis (GPA) is an uncommon pauci-immune small-vessel necrotising granulomatous vasculitis mostly seen in age 45–60 years. We present the case of a formerly healthy 44 years old male presenting with dysuria and intermittent urinary retention for 8 months, not responding to empirical antibiotic therapy and TURP. A prostate biopsy showed necrotising granulomatous prostatitis. Urinalysis demonstrated persistent pyuria and haematuria, but cultures showed no growth. Subsequently he complained of fever, cough, dyspnoea and skin ulcers. CT of the chest showed multiple cavitatory lesions and pleural effusion. On work up, c-ANCA was positive and a diagnosis of granulomatosis with polyangiitis was established. This depicts a rarely seen presentation of prostatitis as the initial feature of GPA.

Objective: To determine frequency of hyponatremia in liver cirrhosis patients presenting with hepatic encephalopathy. Study Design: Descriptive Cross-sectional study. Setting: Department of Medicine, Sandeman Provincial Hospital, Bolan University of Medical and Health Sciences Quetta. Period: June 2020 to December 2020. Material & Methods: Cirrhosis was characterised on Ultrasound abdomen with altered liver parenchyma, shrunken liver and coarse echo texture. HE was defined as a spectrum of neuropsychiatric abnormalities diagnosed clinically with adequate history taking and physical examination. After taking informed consent from the patients’ attendants, 172 patients of liver cirrhosis presenting with HE were enrolled. Detailed clinical history and examination along with investigations were done. Hyponatremia was defined as serum sodium level 3 days was seen in 47 (27.3%) while 125 (72.7%) had stay of >3 days. It was observed that 14 (8.1%) patients expired. Hyponatremia was found in 69 (40.1%). Conclusion: Hyponatremia was a common feature in liver cirrhosis patients presenting with hepatic encephalopathy. Furthermore a significant association of hyponatremia was seen with hospital stay and all-cause mortality.

Proteus syndrome is a rare disease manifested by progressive segmental overgrowth involving the skeletal, Cutaneous, subcutaneous, and nervous systems. We report the case of a 24-year-old female who was born with no obvious abnormality at birth. From the age of 1 year, she developed asymmetric enlargement of her left upper limb and bilateral lower limbs leading to enlargement of the right-hand phalanges with radial deviation, enlargement of the right big toe, lateral deviation of left foot, and discrepancy in the length of lower extremities and kyphoscoliosis. She had become bed-bound for the last few years due to increasing disability. She was diagnosed with Proteus syndrome based on clinical features of progressive course, mosaic distribution, and sporadic occurrence of the lesions.

Background: Chronic liver disease is a highly prevalent illness globally and in Pakistan as well. The current study was designed to investigate the prevalence of anxiety and depression in patients with chronic liver disease (CLD) in hospitalized patients. Methods and materials: Agha khan University anxiety and depression scale (AKUADS), a questionnaire developed natively in Urdu language, was the instrument used for the study. Admitted patients with the diagnosis of chronic liver disease at a tertiary care hospital in Lahore were invited to take part in the study. A total of 107 patients volunteered to take part in the study (29.9% females) from February 2018 to November 2018. Descriptive statistics was employed to report the prevalence of anxiety and depressive disorders in the study population and independent samples T-test was used to analyze the gender difference between the participants. Results: All study participants scored above the cut-off score of 20 on AKUADS. No significant gender difference was seen among the study participants on mean AKUADS scores. Conclusions: The prevalence of depressive and anxiety disorders is very high in patients with CLD. These patients should be assessed for the presence of depressive and anxiety symptoms on a frequent and routine basis. Recognition and treatment of depressive and anxiety symptoms at an early stage may lead to avoidance of many adverse outcomes related to CLD. Keywords: Depression, Anxiety, Chronic liver disease

A 72-year-old asthmatic gentleman with a history of recurrent sinusitis and chronic bronchitis presented with shortness of breath and progressively worsening hypoxemic respiratory failure. His CT chest demonstrated airspace disease bilaterally with ground-glass opacifications. He had peripheral eosinophilia with raised inflammatory markers but negative work up of infection. On further investigation, ANA was positive, titer 1:160, speckled pattern and both pANCA and cANCA were present. The patient was diagnosed with Eosinophilic Granulomatosis with Polyangiitis (EGPA) and started on intravenous steroids and cyclophosphamide. A rare multi-organ vasculitis, EGPA is hallmarked by asthma, sinusitis and eosinophilia. In initial stages vasculitic involvement is not usually seen thereby making EGPA a diagnostic challenge. doi: https://doi.org/10.12669/pjms.39.1.6436 How to cite this: Mahmood K, Butt NI, Ashfaq F, Aftab S. Eosinophilic Granulomatosis with Polyangiitis (EGPA): A case report with atypical presentation. Pak J Med Sci. 2023;39(1):---------. doi: https://doi.org/10.12669/pjms.39.1.6436 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Previous research on the prevalence of depression and anxiety disorders in patients with chronic kidney disease (CKD) has shown a high prevalence of both types of disorders. The aims of this study was to assess the prevalence of depression in anxiety disorders in CKD patients admitted at a tertiary care facility in Lahore, Pakistan. Materials and methods: All admitted patients at one of the medical wards at Jinnah hospital Lahore from December 2018 to December 2019 with a diagnosis of CKD were invited to participate in this study. Aga khan university anxiety and depression scale was used to assess the prevalence of anxiety and depressive disorders. Results: All patients scored above the cut-off points of 19 on the AKUADS. The mean score of study participants on AKUADS was 46 (range of possible scores from 0 to 75). There was no statistically significant difference between male and female study participants on AKUADS scores. Conclusions: The prevalence of depressive and anxiety disorders in patients with CKD is extremely high in the Pakistani population. The possible reasons for this high prevalence could be physical morbidities, lack of appropriate treatment facilities, financial burden, loss of bread winning roles as well as reduced quality of life associated with CKD. Keywords: Depression, Anxiety, Chronic kidney disease

Objectives: To determine the frequency of silent cardiac ischemia in type II diabetes mellitus patients presenting to tertiary care facility. Methodology: This cross-sectional study was conducted from 20th October 2017 to 20th April 2018 at Department of Medicine Jinnah Hospital Lahore. After a detailed history, measurement of height, blood pressure, weight, fasting blood sugar, body mass index of 237 patients were recorded, and electrocardiography (ECG) was done before and after exercise tolerance testing (ETT). Changes in ECG were assessed and person labeled as having silent cardiac ischemia or not depending on the outcome of the ECG. Results: Mean age was 54.9 ± 5.9 (range: 45 – 63) years. There were 144 male patients and 93 female patients The mean duration of type II diabetes mellitus in the study population was 10.0 ± 2.6 (range: 6 – 15) years. The frequency of silent cardiac ischemia was found to be 45.1%. Increasing age, prolonged duration of diabetes mellitus, history of smoking and hypertension, and increased body mass index were significantly related to silent cardiac ischemia (p-value< 0.05). Conclusion: Silent cardiac is quite prevalent in our population that demands urgent efforts to diagnose this condition earlier for better future outcomes.

Background: Diabetes is a chronic debilitating disease. A large percentage of Pakistani population suffers from this disease and its consequences. Awareness regarding the disease and its management is poor. Aim: To evaluate the awareness of diabetic patients presenting at Services Hospital regarding diabetes. Study design: Observational cross-sectional case-series study. Settings & duration: Department of medicine Services hospital, Lahore, from 01-07-2020 to 31-12- 2020. Methodology: We interviewed 100 diabetic patients who presented to the OPD/ER of the hospital. All the participants were selected randomly. A simple questionnaire was used to record the demographic details of the patients as well as their response to a series of 13 questions. The knowledge of the participants was taken to be good if they were able to answer at least 8 or more of the questions correctly. Results: Overall, a total of 100 adults were interviewed. The median age of the study population was 52.06 years with standard deviation of 13.49 years. There were 46 females and 54 males. Only 30% of the patients had sufficient knowledge regarding the disease and its complications. When stratification was done there was no significant association with any variable. Conclusion: There is a lack of knowledge among the diabetes regarding their disease. Even education from doctors is not helpful in this regard. Once patients are aware of the disease and its complications the glycemic control improves markedly. Keywords: Diabetes Mellitus, Poor Control, Patient Knowledge

FLT-3 mutation is a valuable prognostic marker in patients of AML being related with bad prognosis and poor clinical response to conventional chemotherapeutic agents. Frequency of FLT-3 mutation in AML varies from 25% to 35%. The objective of this study was to determine prevalence of FLT-3 mutation in patients with Acute Myeloid Leukaemia.This observational cross-sectional Study was conducted in Department of Oncology, Jinnah Hospital Lahore from 1st October 2018 to 31st March 2019. Patients with acute myeloid leukaemia, aged 15-60 years, of both genders were included. After taking consent, demographic data was noted. Three ml of sample of blood was obtained from each patient and sent for detection of FLT-3 mutation. Data was analysed using SPSS version 20.0. Chi square test was applied, pvalue0.05 significant.A total of 180 patients were enrolled in this study. The mean±SD age of patients was 34.72±14.3 years, among which 38.3% were female and 61.7% male. The mean±SD duration of disease was 3.39±2.8 months. The mean±SD haemoglobin level, TLC and platelet counts were 7.2±2.3 g/dl, 30,913±63,573 per cm and 58.6±52.3×103 per cm. The blast cell (%) count was 69.6±19.8. FLT-3 mutation was present in 18.9%.We conclude that FLT-3 mutation to be present in only a minority of patients with Acute Myeloid Leukaemia having no significant association with age, sex, haemoglobin, WBCs and blast counts.

Anton's syndrome implies the situation when affected patient contradicts blindness in spite of objective documentation of loss of vision, and often confabulate to assert their bearing. It is an infrequent sequel of cortical blindness affecting both occipital cortex and other cortical centers, while patients genuinely act as if they are sighted. Our case report is of a lady, 55 years old, who presented to us with history of uncontrolled diabetes, hypertension and visual loss as a consequence of occipital lobe infarction bilaterally. In patients with evidence of occipital lobe injury and atypical visual loss, an assessment for cortical blindness and Anton's syndrome must be included. Anton's syndrome is most frequently caused by cerebrovascular disease. Any condition that causes cortical blindness may, however, lead to Anton's syndrome. Improvement in visual function after occipital lobe infarction due to cerebrovascular events is limited. Therefore, the management should be focused on rehabilitation and secondaryprevention. Keywords: Anton’s syndrome, Occipital lobe infarct, Diabetes mellitus, Hypertension.

Objective: To determine the frequency of anaemia among patients with human immune-deficiency virus / acquire immunodeficiency syndrome. Methods: The descriptive cross-sectional single-blind study was conducted at Jinnah Hospital, Lahore, Pakistan, from June 25 to December 25, 2016, and comprised human immune-deficiency virus / acquire immunodeficiency syndrome patients diagnosed at least 3 months earlier.. Demographic information was obtained along with sample of patient’s blood for haemoglobin level estimation. Anaemia was defined as haemoglobin 12g/dl. Overall, 152(66.1%) patients were anaemic and 78(33.9%) were normal. Age and socioeconomic status were significantly associated with anaemia status (p

Objective To compare the efficacy of lactulose plus rifaximin with efficacy of lactulose alone in the treatment of hepatic encephalopathy. Study design A randomized controlled trial. Place and duration of study Department of Medicine, Jinnah Hospital, Lahore, from December 2014 to June 2015. Methodology All patients who presented with hepatic encephalopathy due to decompensated chronic liver disease were randomly divided into two groups of 65 patients each. One group was given 30 ml thrice daily lactulose alone and the other lactulose plus rifaximin 550 mg twice daily for 10 days. Informed consents were taken from the participants' attendants. Grades II-IV hepatic encephalopathy was noted according to West-Haven Classification. All subjects were followed until 10 days after admission. Results The mean age of patients was 56.06 +11.2 years, among which 46.9% were females and 53.1% were males. After ten days of follow-up, reversal was seen in 58.46% in lactulose alone group and 67.69% in lactulose plus rifaximin group (Chi-square p=0.276). Conclusion There was no difference in effectiveness of lactulose plus rifaximin and lactulose alone in treatment of hepatic encephalopathy.