Dengue fever and Scrub typhus co-infection deteriorating Severe Acute Cholangitis: A rare case report

IntroductionTuberculosis (TB) is one of the most common global health burdens caused by Mycobacterium Tuberculosis.1 Almost half of the TB cases remain unreported, contributing to the underdiagnosis of extrapulmonary tuberculosis.2 The worldwide incidence of disseminated TB is also in increasing trend. Central nervous system (CNS) involvement is one of the most devastating complications of tuberculosis and is seen in 10% of all disseminated TB cases, accounting for 1% of all TB cases.3 CNS involvement may present as meningitis, cerebral tuberculoma, tuberculoma abscess, and thoracic transverse myelopathy.1,4The predominant symptoms of disseminated TB are fever, cough, malaise, loss of appetite, weakness, and weight loss. In addition, symptoms according to system involvement are often seen, like a headache in the case of meningeal tuberculosis and abdominal pain in peritoneal or intestinal tuberculosis.5Although the treatment of disseminated and pulmonary TB are considered the same, CNS involvement warrants a longer duration of treatment. The four-drug regimen of rifampicin, isoniazid, pyrazinamide, and ethambutol is administered daily for two months, followed by rifampicin and isoniazid for two months. In disseminated cases, these two drug regimens can be extended. There is no clear evidence of the effectiveness of corticosteroids in disseminated TB cases. However, steroids are often used in disseminated cases. 6 Early identification and prompt management are the cornerstones for optimal patient management in disseminated TB with CNS involvement.We reported this case following the updated consensus-based Surgical Case Report (SCARE) Guidelines. 7

Heart Failure due to Peripartum Cardiomyopathy Presenting in the First Week of Puerperium - A Case Series from NepalAbstract: Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure associated with pregnancy without any other known cause. Most of the clinical presentation is similar to symptoms of advanced pregnancy making the diagnosis difficult. Reported are three patients who developed dyspnea, orthopnea, and dry cough during the first week of puerperium. On examination, bilateral lower limb edema and bilateral basal lung crepitation were present in all patients. Chest radiograph showed pulmonary edema in cases two and three, and pleural effusion in case one. All patients had reduced left ventricular ejection fraction and raised N-terminal pro-b-type natriuretic peptide (NT-proBNP) levels. Case two developed PPCM in the background of left pyelonephritis. Case three was complicated by acute kidney injury. All patients were managed with bromocriptine, diuretics, beta-blockers, ACE inhibitors, and fluid restriction. Hence, PPCM though rare should be considered as a differential in women presenting with features of heart failure in later months of pregnancy or within five months of delivery.Keywords: heart failure, bromocriptine, peripartum dilated cardiomyopathy, pregnancy, peripartum cardiomyopathy.Introduction-Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure affecting women in the later months of pregnancy or within five months of delivery. PPCM often presents when peak volume load, reached just before delivery is greatly reduced after delivery.1,2PPCM affects women from all ethnicities globally with wide variation in incidence from 1:20,000 live births in Japan to 1:100 in Zaria, Nigeria.3,4 With a prognosis that can vary from the complete recovery of left ventricular function to maternal mortality as well as recurrence with subsequent pregnancies, the study of PPCM has been done sparsely in Nepal.2,5 This case series attempts to increase awareness of disease, diagnosis, and treatment in Nepal.CASE PRESENTATIONCase 1A 33-years lady, G2A1 at 38+6 weeks of gestation, with no significant medical history underwent emergency LSCS for non-progression of labor secondary to arrest of descent. On the 4th day of puerperium, she developed dyspnea on exertion, orthopnea, bilateral lower limb edema, and dry cough. On examination, she had increased blood pressure (160/110 mmHg) and bilateral lower limb pitting edema with bilateral basal crepitation on chest auscultation. Chest radiograph showed bilateral minimal pleural effusion. Transthoracic echocardiography (TTE) showed severe left ventricular systolic dysfunction, dilated left atrium (LA), moderate to severe mitral regurgitation (MR), severe tricuspid regurgitation (TR), moderate pulmonary artery hypertension (PAH) and reduced ejection fraction i.e< 25%. ECG showed T wave inversion in leads V1-V4 and aVL (figure 1). Serum N-terminal pro-b-type natriuretic peptide (NT-proBNP) was 10897 pg/ml (Normal <300). With the diagnosis of PPCM, she was managed with fluid restriction, diuretics, beta blockers, angiotensin receptor blockers (ARB), bromocriptine, and antibiotics. Repeat TTE done on the 12th day of puerperium showed EF of 30%. However, she had 3 episodes of syncopal attack on the 19th puerperal day which was probably due to orthostatic hypotension. She was discharged on the 22nd puerperal day with oral ARB and bromocriptine and with close follow-up with cardiology and obstetrics and gynecology clinic.