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Cochin Clinical Society Meeting December 2021

Dec 16 | 2:00 PM

The Cochin Clinical Society presents an intriguing set of five cases presented by faculty members from Amrita Institute of Medical Sciences (Amrita Hospital), a leading multispecialty quaternary care health center in Kochi, India. 1. Dr. Vaishak Anand: Let Food be Thy Medicine: Ketogenic diet therapy in pediatric epilepsy 2. Dr Suma Balan: A Swollen Knee & A Swollen Head 3. Dr. Soumya Jagadeesha: A case of Psoriasis- What can happen with an alternative 4. Dr. Mira Nair: Taming the Dreaded Villan 5. Dr. NR Sreehari: TIA or SAH or Both? In one- A complex clinical scenario in cerebral vasculature

and now we have under the institute of medical sciences with very very interesting five phases with lot of diagnostic challenges and clinical achievement exemplified in all these five pages so i think all the presenters are ready and they can keep their presentation to maximum 10 to 12 minutes so that we can have a description of these five minutes in each of these phases so and all the audience can put their questions in the chat box and we will try to answer when we can also i would like to thank the well as i thank the organization and picks for this wonderful platform so without any further delay i proceed to my presentation that would be the high medicine we had a two and a half year old girlfriend normal boy who was born out of a third degree gonzaga's marriage uh he presented to us with a history of return force but there was no loss of consciousness and it was being operated for last 10 months associated with uh this was recurrent jerks of trunks and mother complete that at times he will go black and please stay for four to five seconds uh these episodes were more in the mornings but he never had any torn chronic seizures uh other systems so uh basically we have a normally developing toddler without any significant penetration or past history family stream now presenting only treatment force and some jerks with a normal uh neurological examination so faults in children is a pretty common condition but it becomes significant if uh it is more to the extent that it interferes with the daily activities will lead to different trauma etc so most of the time it's extraordinary process only like uh mainly cardiac causes like arrhythmias etc but in our case it was not fitting into that another neurological process the non-ecliptic causes like cerebral hydroxya sensory techniques it also can lead to recurrent force even dystonia means that the abnormal twisting postures are known as destroying dystonia if it is more in the lower limbs it can lead to cause even lower limb element weakness like muscle paralysis uh uh there's no policy etcetera that also can lead to false but here uh the examination neurological example is perfectly normal so we are left with only epileptic causes so different types of seizures current presence are false it's not that seizure will every time have the dramatic presentation of tonic-clonic moments as we see in movies a lot even subtle uh forwards also may be uh epileptic like in action seizures where there will be a certain loss of torn lead leading to fall myoclonic seizures where there is a certain jerk of the trunk leading to fall tonight's issues where there is a tonic positioning of the uh of the drum leading to form so uh considering this as an epileptic phenomenon we proceeded with so uh this was the eeg of the kid uh so you can see this is a 12 second ebook where you can see it is completely almost full uh spike can be discharged you can see these are the poly spikes and waves that we can see these are known as generalized polyester views which are epileptic so there are hardly any seconds where it is not there so it is completely full of discharges along with this intricate we recorded three types of events so the gold standard in diagnosing a movement uh to kind of differentiate with the association or decision-like moment the oversight is that we should be recording the recording payment with the corresponding eeg to see if there are types of events one was a atonic seizure where the child suddenly lose the tone which was presenting as the twelves forced by the mother micronic seizures which presented as jerks and a typical absence seizures where mother was complaining that he would be staring for four to five seconds along with that indirectly he was uh showing generalized foreign so we diagnosed a condition known as micronic acronym epilepsy otherwise known as the dough syndrome named after the doctor who i recognizes the first time it is a rare early childhood once a day lipid concealer usually it starts to occur in developing normal tourists but the poorest issue can lead to long-term neurocognitive impairment the significance of recognizing the syndrome's lies in the fact that apart from the normal uh traditional anti-applicable drugs this particular syndrome responds significantly to dietary therapy that's ketogenic therapy ketogenic dietary therapy basically involves reducing carbohydrate component of the there are only three types of ketogenic diet one is classical the other is modified basically simple sugars like chocolate sugar completely the last six months is the eeg that was done three months after the dietary initiation you can see there is only one place where there is a generalized forest factory so uh up to one third of periodic epilepsy will be medically interactable that means it will not be respond to the normal uh the usual antioxidant drugs that we use and it is termed as the crystalline eclipse or dre so the management of drama involved but uh let us go through some of the historical aspects of that how it started important was that it was recognized that fasting first it can lead to decreasing seizures that was known even in hypocretic times even in the bible it's mentioned that fasting can lead epilepsy with fasting this particular verse in the bible will be uh favorable to all of us matthew 17 where he jesus comments that if you have the faith of the size of a mustard seed you can move the mountain so there's a pretty very famous verse what follows that verse is that jesus commands but this kind goes uh does not go out except prior and faster this kind means epilepsy so there's a comments that frequency does not go except by trying fast so prior uh product is not our domain out of minuses uh this is the uh the famous painting known as transfiguration of jesus which was done by raphael and that particular scenario was depicted in this picture where you can see i have circled it the child is in positive state supposedly it is cured by jesus coming to the moderating history in 1921 it was recognized by dr galen that uh it is the starvation peter serious that is leading to the idea of fasting the same year doctor wilder published a report that it's mentioned that high fat low carb diet can lead to ketones making a state of fasting and can have idea dr wilder is considered as the father of ketogenic diet and he coined the term much attention further because there is a milestone discovery in 1938 in april 201 till that time it was only phenomenal sodium bromide extract that was used for epilepsy and after peritoneum multiple antioxidants were discovered like carbons of invalid etcetera and then it was the era of anti-flipping drugs and the ketogenic diet gradually for nearly half a century it remained in oblivion till 1993. in 1993 uh 20 month old charlie abraham who had medical refractory epilepsy was treated with ketogenic diet and he achieved complete seizure freedom that was at johns hopkins institute at maryland next year jim the father of charlie abraham started charlie foundation for promoting research and raising awareness afterwards there are a tremendous increase in the uh tremendous increase in the research of ketogenic diet and currently ketogenic diet is uh the standard of care and pediatric eclipse in all the major centers of liquids in the world there are many groups like charlie foundation like matthew's friends basically as i told there are three types of classic uh ketogenic most compulsive and most restrictive one is known as classic ketogenic diet uh and it has got the most evidence also in efficacy the other ones are more foreign because of the combustion uh um the cumbersome uh to prepare yeah classically it's compulsory prepared and also very restrictive also leading to complex issues that's why less restricted diets like modified atkins diet and ljt came to be even this modified acne diet and ljd also have a comparative efficacy classical regarding the indications for class uh ketogenic diet therapy age is uh not a limit for uh starting ketogenic diet therapy even in neonates there are multiple reports of knowing that that can be used using the picture formulas there are two conditions where ketogenic diet therapy is the drug is the uh therapy of choice first line um one is glucose transportation and one is pyruvate uh rehydrogen glucose transportation is where the glucose transporter in this in the blood vein varies absent because uh we all know that the glucose are no transporters are not under the control of usury and blood glucose pulses to the csf so in this particular condition these glucose quarters are absent and brain is uh deprived of glucose so if we give ketogenic diet therapy the ketos the ketone bodies will be crossing uh cso blood brain barrier without without the need of this glucose transporter providing alternative the other conditions where kdt can have a significant effort here one is two syndrome we already know microbiota tuberosis complex syndrome infants syndrome which is otherwise considered as a related factor it is also not free of any adversity it has multiple atmospheres the most common adverse effects are gi related like vomiting constipation produced etc rare but major adversaries are rainstorms hyperlipidemia metabolic acidosis etc because kd is a restricted diet uh the kids are proud for micronutrient deficiencies like io and vitamin d etc so supplementation of uh these micronutrients also is very important uh this is actually one of our children who was on pdt presented with severe pain and stopped walking uh the x-ray showed that he was having all the classic features of a four bottle disease which is curvy you can see the pencil thin cortex surfacing hemorrhage uh white liner frankl the so we started on vitamin c and within hours he responded well apart from epilepsy there are many other conditions in periodic neurology where ketone therapy can be used mainly neurodevelopment disorders like would some hyperactivity adhd etc some degenerative conditions like parkinson's the magnetic conditions also like multiple sclerosis and neuromyelitis optica etcetera uh these conditions also k d t but the robust evidence is yet not available and we can wait so basically ketov is a safe and efficacious intervention for recreational wfc particularly in children it's efficacy in other neurological conditions and psychiatric conditions it needs a comprehensive team including train dietitian neurologist and pediatrician case is open for discussion therapy just for important and educational listeners here which type of epilepsy do you you feel it is more useful the focal ones or the generalized ones like like actually there's no comparative errors but from the from the extreme so i think it's more likely because focal activity uh if it is more focused most of the time will be having a surgical uh substrate like a total cortical disc temporal skeleton so most of the time surgical correction so it's less common that we go for brain damage neonatal hypoglycemic result can lead to multiple cochlear generalization yeah and secondly uh doctor uh we learn from literature as well as your presentation that the basis is basically trying to maintain the ketone level [Music] um we do not usually uh check urine ketones or which are curing drugs not serum ketones in classic kd that's classic eternity that we routinely have urine and whether it's made two plus or three to the two plus three plus ketone ketone uh levels are maintained or not which have been classified but in mad and delicious we do not say basically the mechanism does not involve only the ketone ah because multiple studies have um have been done the external ketones were given through orally to see whether ketonemia will correlate with the seizure reduction but studies have shown that it's not the scenario it does not mean that rising the ketone levels in blood correlates at some more otherwise obviously yes we monitor using the c reduction and there is no uh desirable reduction is if uh adequate seizure reduction is not achieved we go back and check the complaints whether they're following proper proper diet or they are like uh inadequately giving some sugar somewhere like most of the time we'll be converting all the serum children most of the time they will be having medications zero formulation which contains sugar so we change from zero to uh tablet form even we change the toothpaste we ask them to change the toothpaste the normal colgate for close manner we ask them to be i was just wondering if this uh syndrome or the micronic episodes which this child had the total i understand that it's a total operation yeah do you uh have any specific ocular signs at the time of the attacks like you know downward case or or uh nystagmus sort of thing which is characteristic of these attacks yes we do get like in myoclonic if mitochondria is there most of the time we get there there is upward period [Music] isd and also the morgan body positive cases also may present like this microchronic jerks and so so in a routine when a case is presented like that would the investigations would include a investigation by a number like the like the aqp for or the emoji antibodies as well usually emerging food antibodies do not present seizures and civil rights but we do not persecute the presidential is very unlikely for a demonstration okay then i think thank you thank you thank you very good very good presentation thank you so i invite dr suma with a very very rare presentation i believe and a very interesting case from the department of affiliate [Music] talk to you about a four-year-old boy who came to my clinic a few months ago uh he was referred as a periodic feeder but the onset of symptoms were from three months of age and he had actually been seen previously in october 2017 at which time he had persistent fever he had very uh you know his couch there on the higher side he had uh there was this feeling that he was getting recorded infections because he had inflammatory markers were consistently elevated and uh on examination he had the hepatosplenomegaly [Music] but somehow because that history fell in at that time it was a sound strong suspicion this could be a primary moon deficiency particularly what we call a leukocyte adhesion deficiency and he was ex exhaustively worked up for primary immune deficiencies and you know nothing was found he was worked up in two centers at this point three major centers he had a bone marrow lymphoma a lot of work done no specific diagnosis could be important the family were very disappointed at this time because the child was not improving and they went to alternative medicine where they were pursuing for three years prior to just referring to us and so he continued to have when we saw him in june 2021 he was continuing to have his fights he was getting a rash almost every day he was not at all thriving very poor appetite and uh you know and but when i looked at him what struck me were two things one is that he had a very big head he was extremely irritable extremely extremely irritable the parents thought it was hospital appearances that were making him actually business and he had a very very large right knee so it was referred to me as a case of arthritis and so i actually speaking having the luxury of seeing everything that was done so far it was not difficult for me to pick up the diagnosis since i was aware of the condition but it is a very very rare condition and he i will show you a picture so to summarize at this point he was a four-year-old boy with symptoms from age three months but we persistently almost every day every other day with rash failure to cry very very painful not being able to bear weight on it he also had an open fontanel waist pressure and you can see this is this picture where he's standing with support and he has frontal embossing and he has his right knee it was not arthritis you can see how wasted the it is used but when you look at the x-ray what you're seeing is actually bony hypertrophy of the air of the epiphysis and this is something that is actually quite unique to growing children as an adult many inflammatory diseases do not affect growth but in children because the epiphysis is so much growth left many chronically inflammatory diseases can actually affect growth so he has abnormal widening coupling of the discrimination enlarged hypothesis and this was picked up even on ultrasound and so we knew i by now knew what this condition was and we look at his baseline investigations when he came to us actually when he was seen as an infant he had very mild animal hp 10.8 when he came to us in june his stage 4.3 he has very high white counts he has thrombocytosis all of which indicate inflammation chronic inflammation and uh you know an energy ratio which is reversed which also indicates chronic inflammation and he had very high inflammatory markers as you can see here and you can see that he is now on treatment and all that is much better so early onset condition with regular fever and rash severe inflammation hypothesis and cms this is a condition called neonatal onset multisystem inflammatory disease it's called moment or silica synthesis the same thing chronic inflammatory neurological cutaneous and arthritis like arthropathy manifestations this is a condition for falls under the umbrella of cryofire associated prolonged symbols which are basically due to mutation in the mlrpg gene which is a gene that covers there are three conditions which come under this iron associated periodic symbol which we abbreviate the caps and uh you know that this is actually a spectrum from the first one f gas or familiar word authenticators are much minders by end of the spectrum and moments which this boy has and the problem if you leave him untreated he can actually go for amyloidosis he can have severe deformities he can become blind and his hypothesis can become very risky so there are many many consequences for a child like us so what are auto inflammatory diseases i think you know we are aware of infections we are aware of autoimmune diseases we are aware of malignancies immune system which are characterized by spontaneous concept of exuberant inflammation they're not due to infection we usually don't have autoimmunity or energy and left untreated they can have devastating consequences about 40 years ago we many of these were syndrome types nobody really knew what caused them in 1997 the first diagnosis of uh you know the gene for familial people was fine at which time shortly after that over five periodic figures were known today we have more than 50 55 and new ones have been bypassed all the time so this is a group of conditions we have to be aware of because we are not only devastating if left completely [Music] [Music] control we also started thalidomide because that is the only kind of anticipated drug we have in india what actually inhibits this condition is il1 interleukin-1 receptor antagonist and this is one of the drugs is called anikindra it is not available in india we have sources from abroad it can be quite expensive [Music] so this father is a media man he managed to get some csr [Music] actually he needs this disease needs to get into the rare diseases initiative group needs treatment supported from the government so he can continue to try and do that and this is the standard of care it's very unfortunate [Music] stop the other treatments that he's on and you can see him now he's running around we also confirmed the diagnosis we sent off regime and we confirmed that he has misunderstood and so now the family knows the father has actually returned to the ministry and his case is being heard in the next five disease initiative group at the ministry level so hopefully this will be a start for this child and other autoimmunity disorders who can include the environment initiative and access so my take-home messages are that these kind recurrent persistent stereotype will be was especially beginning in early childhood please think about this group of conditions called autoinflammatory results we assess them in dermatology we actually at present are fortunate enough to apply them to a good research project by which we are able to do genetics free of cost for these patients at a very high standard and we need to improve our awareness of those children because if we make these diagnoses we can treat many of these children very very well not all the conditions need uh some of them will do well on simple medications like some of them need other medications that are already available in our country so it's a case of being aware and making such differences so that we can have and we create our own registry of these many things first thing of course the skill in diagnosing rare conditions that is a hallmark of the department of rheumatology we all know and the second is also it exemplifies the corporate social responsibility arm and treatment of these unfortunate patients and third as you rightly highlighted towards the end of the importance of cooperation between various institutions like the one in so the case is open for discussion and the general medical paternity in our knowledge of the physiology of community and ecology conditions gets arrested after mbbs we don't read much about at least the surgeons like me but for the benefit of the listeners could you please highlight for us in a nutshell like you did so during the presentation like how to differentiate between auto immune diseases and auto inflammatory diseases like these are two i believe completely different ecologies but then for a late so most of the auto inflammatory disorders are as i said they're disorders of the innate immune system whereas after immune conditions are disorders in the acquired immune system and the inner immune system is mainly through the you know the neutrophils macrophages but to some extent the t cells whereas the adaptive the acquired immune or the adaptive immune system is mostly the b cells the antibodies these so basically most of the diseases of the innate immune system do start quite early so that is a clue then and there is a lot of overlap i mean autoimmunity is one into the spectrum or to inflammatory and primary immune deficiency these are all completely you know integral conditions on the same spectrum one and two so i think it's more about thinking of the possibility of any of these and rather what happens with many of these patients is they keep getting recurrent courses of antibiotics because they have fever they have raised in chemical markers we give them antibiotics that's what we give more antibodies then we give more and we keep on thinking of infection which we need to think outside the box in these situations and doctor one more thing closely following our case uh you said this child had a rash like any particular type of rash you were expecting like arctic areas yes they have a rash that looks very earthy and that's what they tend to have and exposure to cold actually makes the russian worse so and these particularly these children the rash comes almost every day can be actually quite painful when it comes as well in this context and one more this long term prognosis like because it's a basic defect in the genetic world i mean genetic trait in this children so now we have given an ielts interleukin inhibitor do they continue to need this rare medicine throughout their lifespan or yes actually because he has a mismutation he actually does need it lifelong listen it's a daily injection that he has to take i would say put it this way i think this is relatively a young group of conditions and we are still learning and you know we won't have 30 years follower that kind of thing is not there because you know confirmation and follow up for these conditions there is not that much of experience yet and there are so many other treatments so many other immunologically based treatments that have been evolved worldwide it's quite possible in 15 20 years we have different ways of approaching these patients perhaps stem cell transplants other things would be much much more technique and they do very well the first group i said the f gas patients there are a good number of patients who are on this medicine and their their delivered babies they are living very good lives while we are waiting for questions from the audience of course philosophically speaking the stress on the early part of the presentation neonatal itself at the other end of the spectrum as we grow older the same auto inflammatory thing raises its head in the form of the frequency of hypertension without atherosclerotic chronic disease so these are also in a way auto inflammatory isn't it yes yes any questions but they are not [Music] this is a situation where you don't it's surgical treatment is not going to help this child it is you work on the inflammation and it reduces it just completely reduces so this is a chronic aseptic meningitis yeah so thank you dr suma well presented and very eye opening type of a case let's move on to the third case presentation of today from [Music] the department of dermatology dr samya with an equally rare presentation of a overlooked condition in the society over to your doctor thank you thank you uh dr subramanian sir for the introduction and for sharing these sessions beautifully and once again i'll move on uh straight to my presentation after uh thanking and acknowledging coaching clinical society and the organizers and medifix team for giving me this platform so i'll be uh just speaking about a case of psoriasis a very common condition that we dermatologists see day day in and day out what can happen with an alternative so i'll cite this code before i begin it is not only for what we do that we are held responsible but also for what we do not do this lady she is a 65 year old homemaker from central kerala who was a known case of chronic blood psoriasis on weekly methotrexate oral methotrexate treatment uh from my from me itself since the past many years and she had missed follow-ups in six months and she presented after this miss follow up with an examination of skin lesions so i think many of you may be familiar with the fact that this is a common condition in kerala even when the patient is doing well when they have chronic skin diseases there is a tendency to sometimes miss follow-up and get into the uh you know get into the mindset that the disease is not curable the term cure is often applied though the patient is doing well clinically with no lesions doing good on medication there's always this tendency to sometimes miss the medications or you know go for experimentation so this was a similar case and she reported with exacerbation of skin lesions in one month after missing her medications but what was interesting here was that the morphology of the lesions were different when respect with respect to the previous lesions because uh in psoriasis you generally get generalized uh erythema with silvery scale plaques whereas here there was generalized hyperpigmentation near epema with minimal scaling and a sort of charred appearance as you can see in this picture there is not much erythema not much redness more of a charred kind of hyperpigmentation not much this is not the usual psoriasis-like appearance that we see but anyway since she had missed medication we provisionally kept the diagnosis of an exfoliative psoriasis which can present with atypical manifestations and we also thought about the possibility of a methotrexate toxicity methotrexate is an oral tablet that you take weekly once but it often so happens that in spite of instructions patients sometimes take it daily which can end up in methotrexate toxicity and which can give rise to this kind of a charring appearance but the patient repeatedly denied taking the drug at all for the last six months so anyway we decided to admit the patient a biopsy repeat biopsy specimen was taken from the charred kind of lesions and she was started on injection method injection methotrexate subcutaneous methotrexate along with supportive treatment what happened uh further we got the uh histopathology opinion from the biopsy specimen and uh it wasn't very typical of to cut the long story short it wasn't very typical of a psoriasis it was more like a lycanoid kind of pattern with basal cell degeneration and this is an appearance that we usually see when you have a drug reaction so we did consider the possibility of a superimposed drug reaction over this in this particular case and even while the patient was on treatment with supportive management and injection injection methotrexate the redness and scaling increased she also had a one-month-old leg ulcer which was noticed at the time of admission which was on the right leg just above the ankle and the patient and bystander were repeatedly complaining of oozing a silvery kind of liquid from the lesions though we did you know we heard this the first time itself when they were admitted we did not give it much much significance but uh we did try to see we did try to explore the leg ulcer to see what they were complaining or what we found it very strange that kind of silvery liquid is oozing from the lesions and what followed was this see that silvery liquid that quickly contends to form a silver kind of a ball this is what we saw this is exactly what you see in your thermometers so without further testing this was evident that this was a mercury droplet that which we we could find from the so we found this extremely curious and very strange that you know mercury globules are popping out of the ulcer and we did question her regarding whether there was any thermometer injury whether she was consuming fish in large quantities whether she was you know they were doing some gold kind of work in the family but everything you know she denied all these kind of history but she admitted to using herbal medication from a local practitioner of alternate medicine both oral as well as local applications since the past six months while she had defaulted the treatment however the exact details were not available she just told us that she was consuming an oral powder form as well as she was applying a liquid form over the whole body again this had us really fast i mean we found this very strange and curious and we tried to kind of we uh try to get the actual medication uh from the patient but the family somehow wasn't very interested in going back to the practitioner and they said that you know it is not possible they have exhausted the sources and it's not possible to get there anyway so uh we took an x-ray of the right leg and see this is what we found you can see the radio opaque metallic densities distributed on the anterior and lateral aspect of the right leg the middle and lower one third of the soft tissue plane so um we didn't stop there we also did a biopsy from the histopathology from the ulcer side and you can see the the mercury deposits the round black extracellular mercury deposits surrounded by necrosis so we discussed uh the this with our medical forensic team and pillars especially and we did the blood mercury levels to see if there is any systemic toxicity involved and the initial blood mercury levels were found to be really elevated 101 where the reference range the higher range is 7.5 we did not take it very uh seriously because there was a possibility of contamination and a repeat estimation to eliminate that possibility also showed a very high blood levels of mercury so um this necessitated detail evaluation of the patient by the physician and all the other concerned specialists now there wasn't much of talmudic or auditory involvement neurological examination showed muzzle weakness and tremors the patient was also she also had complained initially itself was insomnia and irritability which we had attributed to the exacerbation of psoriasis uh other blood work of especially the renal parameters and electrolyte levels were within normal limits uh nerve conduction defects uh uh were also found uh we found a decreased amplitude in both the limbs in the peripheral nerve conduction test so with this uh we diagnosed this case as a cutaneous mercury granuloma with probable mercury toxicity and why cutaneous mercury granuloma because of the typical finding of mercury deposits in the skin with necrosis and also because of the subtle neurological signs we were not able to completely eliminate a possibility of toxicity and also the high blood levels of mercury and after much discussion because the course wasn't very clear on how to go about this case and we decided to give chelation therapy with the pencil amine and fortunately the symptoms rapidly improved post chelation and in two weeks there was actually a reduction in her skin symptoms as well the charred appearance and the pigmentation started resolving the ulcer eventually healed we continued the patient on methotrexate for her psoriasis and she was she was also given psychotropics for her psychological support counseling and the patient was discharged and you can see the improvement in the pigmentation so this brings us to the discussion of what we all face we face it a lot in dermatology i'm sure many of us face regardless of our specialty this common perception that traditional medicine is safe medicine so this popularity of alternative medicine is on the rise especially as far as chronic disorders go public perception is that they are natural and so they must be safe heavy metals are an integral part of many indigenous preparations and they are actually supposed to undergo processing and detoxification to make them enough but there is little or no regulatory oversight of this seldom happens in fact we browse through many studies done on this topic looking at the levels of heavy metals in alternate medicine preparations ayurvedic or other alternative medicine preparations and surprisingly one third of them were found to have arsenic or mercury levels and even lead levels uh grossly exceedingly safe levels and especially certain power which are common i will not take the name this is the intention of this is not to malign but to be aware that these these preparations may contain these metals and so that we proceed accordingly so worldwide analysis reports of preparations reveal heavy metals far in excess of safe limits so as far as mercury goes it's a heavy metal that exists in three different forms elemental inorganic or organic all three forms can be interconverted in the environment and can cause toxicity so the presentation of the kind of toxicity depends on the form of mercury the root of exposure whether it's inhalation topical ingestion or injection and also the duration of exposure and of course mercury saws the inorganic ones are more prone to cause gastroenteritis and acute kidney injury organic mercury especially the methyl mercury has traditionally caused logical and teratogenic effects due to effects on the brain and the developing embryo and interstitial pneumonitis and neuropsychiatric symptoms have been found traditionally with elemental mercury vapors so regarding because i'm not an expert on mercury poisoning as far as the presentation and skin goes this case was particularly interesting for us because cutaneous hyperpigmentation has been documented with topical or occupational exposure to mercury many of the fairness creams contain mercury inorganic salts of mercury and lycanoid skin reactions have been reported especially to the mercury which is contained in the tattoo ink there is also a mercury example which is known as the baboon syndrome which occurs in patients who have mercury allergy due to a after repeated exposure contact dermatitis has been reported or a lycanolic reaction or oral lichen plainness likations have been reported after exposure to amalgams in mercury especially those who have had denti fillings previously 10 to 12 year old fillings and ecrudini or pink disease is being seen especially in children due to exposure in any of the three forms the elemental the organic or the inorganic forms uh considering the cutaneous mercury granuloma that we were dealing with here it usually occurs due to direct inoculation of elemental mercury in soft tissue there you get a localized granulomatous reaction this has been particularly reported after trauma especially in healthcare workers you know the classical thermometer breakage and spelling rarely self-injection or applying application of mercury containing topicals systemic toxicity is rare though it has been reported in few cases following uh cutaneous mercury granuloma and in our case a repeated application of preparations containing mercury on wounds we have been shown to induce granulomas and we hypothesize we can only speculate that this must have been what that has happened in our case so i present this case just as a an eye opener and some some points to ponder on that growing popularity of traditional indian remedies necessitates a critical evaluation of the associated risks so we as treating physicians should be aware of the varied presentations of heavy metal toxicity and that there is a possibility of this in our case we were quite unaware of such a possible because most of our patients do consider alternate medicine at some point of their many of our patients do that so it is important imperative that we are more aware of the manifestations of these toxicities and as far as the governmental guidelines go we need more pharmacovigilance quality control measures to minimize these adverse events and dermatologically mercury toxicity is especially relevant considering the popularity of fairness creams tattoos and so on and we need actually more studies on the cutaneous features of mercury toxicity we uh actually we have reported this case as one of the uh you know case which shows pigmentation or lykinoid reaction with cutaneous mercury granulomas so thank you everyone excellent excellent case dr somia coming back to your initial slide it's not only for what we do we are held responsible but also for what we do not do so the audience for those of you who will ask questions you will learn or those of you who don't ask questions you may not learn many so please actively participate it's a very interesting case it exemplifies a lot it gives a social message also surprisingly in this part of the country where literacy level is very high but still people call for various alternative therapies and just to add on to what dr somia said interestingly also this part of the country has mercury poisoning was in the news recently and every year it keeps hitting the headlines especially because the mercury is found to be more than 20 times higher than the permissible level in the river period from where we all consume our most of the seafood aquatic fishes uh all of you must have heard about dr anu gopinath she is a researcher in the forest i had opportunity to read most of her papers on this topic a few years ago so very high mercury levels in this part of the state in the peria river which is causing a lot of poisoning of the seafood especially the benthic that is the seafloor fishes so questions from the audience also as she pointed out correctly towards the end of course in a very very soft and subtle manner uh the audience will be surprised to know that one of the india's leading ngos that is the center for science environment recently i think last year published their survey on the fairness cream brands in india and you'll be surprised to know that 44 of all the indian fairness cream brands have mercury despite the fact that the drug in any skin preparation so any questions from the audience it's a really indeed a clinical achievement of the team there in dermatology to pick up the diagnosis and to go ahead only with the treatment for chelation so dr samia one question how frequently do you see i mean heavy metal poisoning cases in your department like average not very frequently sir because unless they present to dermatology this was like a dermatological manifestation of the presentation i guess the renal team in nephrology team the neurology team they get to see more often cases of heavy metal the cutaneous presentation is not very common so this was one of the rare cases yeah you're correct in neurology also in the society coaching clinical society i when i was a secretary we had a separate session dedicated to heavy metal poisoning and its various neurological manifestations it's a it's a brain country exactly i i'm sorry i forgot to mention about the arsenic toxicity arsenic toxicity we do see sometimes uh it does manifest in uh it does present on in the skin especially our colleagues from west bengal they keep presenting them in dermatology it's though a little more rarer in this part of the world but arsenic toxicity we do see and sometimes lead toxicity uh you know manifesting as pigmentation pigmentary changes that also we see but i guess yeah like you said dr gopal has commented oct can help complement the diagnosis in heavy metal poisoning i think he must be mentioning regarding the deposits in the eye regarding the heavy metal not deposits yeah basically the thickness reduces the retinal nerve thickness the macular thickness the coronal thickness all those significantly reduces in chronic mercury toxicity we read that in organic mercury poisoning uh there is an involvement of the sensory as well as the auditory so perhaps this is useful lady sure listen dermatological uh you know when you are using it as a cream that i am not sure i'm talking about internalizing internalizing right right now correct dr gopal because in the mercury in the aquatic environments especially the problem we are facing in kochi they easily get transformed into methyl mercury which is far more toxic to humans than the inorganic variety and there is a lot of bio magnification which spreads across food webs more readily than other types of mercury and we become victims because we consume a lot of seafood in this part of the country so the minamata disease which was due to this methyl mercury personally right so with these remarks thank you dr samia for that interesting case we go to uh the next case from the department of neurosurgery dr srihari good evening sir thank you for your mutation and thank you organization for giving me the chance to present uh i started to go into the presentation actually this is a very interesting case presented in the neurosurgical department of severe headache of one week duration she was already on 90 places for cad and hypertension diabetic poverty on and she had one episode of ta she had the weakness of the right side and this ratio one month back so she recovered well and it was started in the dual antiplatelets first started in the lab lawsuit mri uh i also showed the similar left side that can be capsules in fact so we did mrng also and she was preferred here for father management emma ranger showed a bilateral correct stenosis left side more than right and left vertical origin sinuses and the left weak hormones so the same vessel has two pathologies this is the mri geogram showing the xenos bilaterally and the narrowing of the particular origin in the left side and this is the picom aneurysm the arrow is pointing on the aneurysm both the symptomatic regions are on the same measure the headache was actually on the left side a lot of lives and like typical like thunderclap take what you described for a subject called hammocks but the mri or ct did not show it in blood so this is another view now we proceeded with an angiogram the angiogram showed a almost eighty-five percent surface icao and there are multiple plaques above us above and the circular aneurysm was noted in the become and the origin of the posterior civil artery is a heater fetal type so the near the origin of the pca people you see the advertisement and it is around above same centimeter i mean seven millimeter seven into six point one into five point eight this is a detailed uh measurement on the left i see significant state of sound is from the symptomatic side now completing the angiogram on the other side here also we are seeing in xenos but it's not that bad as the other one is asymptomatic around 55 percent and rectangular results are fine and the vertical angiogram showed good the p com on the right side and there is an original stenosis of the leftover so we have three disease division and an aneurysm in the induction and this is the detail picture of the aneurysm the left become now this stage this is a clinical picture to summarize there's a reason not such headache was it a warning leak or central hemorrhage from the aneurysm uh since the ct and mr picture were not suggested because it was not done immediately because then almost five to seven days later it did not show any hemorrhage lp confirmation was usual victim but thing is with the onset of use of antiplatelets which cannot be stopped in view of the cid you can't proceed for such invasive uh diagnosis procedures and we have a ta due to carotid sinuses which is symptomatic of the ica so we can actually uh get opinion from the audience also we can put up in the poll there what are the treatment options whether to go for a surgical or an endovascular treatment ah so you will see the poll options on the screen you all can start uh selecting your option and then you can submit your voting so 91 would go uh with the endovascular option okay i think that is the best option here uh i'll just describe why surgery is little difficult here because antibiotics or indications of cad uh this cannot be stopped and it is difficult to do craniotomy with that so flipping an endothermic though it is could be a longitude giving longitudeness for the treatment but uh this is not possible in this case because of the antiplatelet usage and have general condition endovascular stent and sending and coiling as also has technical issues but this is the option at present as far as the audience also agree with this now coming to treatment plan whether to treat both predominant aneurysm alone or carotid sinus alone or doing both audiences the management part is very confusing and the plan is also all over the world confusing that's why i am taking your opinion also uh y'all can select the options as before and then submit your words in uh so 76 percent of the people would choose aneurysm coiling with carotid stenting in one step thank you we also chose the same option we also thought in the same manner because literature supports that i'll come to that later if you can treat both in one step that could be ideal because the subjection of a procedure for this kind of sick patients are easier but the problem the challenge in this particular year to treat the aneurysm through a cenoterism without uh you know damaging the blood disorder without a symbolic shower and we can't leave this alone because both are time bombs one can produce another life-threatening catastrophe other can produce a major disability because of the less dominant hemisphere is effective now coming to the procedure what i have done this was a endovascular plan plan in such a way that without damaging without having any risk of embolization we place the stent and with the available space in the stem so that the lesions are secured into the vessel wall and through this tent by boiling the aneurysm then while coming back if you do do for securing the aneurysm you revascularize through illuminatioplasty so this was tried this is the best procedure we can see in the detailed analysis we have skip lesions the arrows are showing so using a protection device or not that's another question when you are doing standing here is some technical difficulty because you have multiple lesions above the actual stenosis and you require a three to four centimeter healthy vessel to place that protection device then there is a sharp curvature that also causes difficulty in securing the device properly so we kept as a backup and procedure without watching device this is a procedure actually most of us aware of this with regular stabilization protocol patient could not operate for a conscious attention we have to start with g only right thumb rule approach and uh long shift access for uh exchange law of the short sheet and we proceeded with extending and coiling this is a procedure this is reaching the lesion because you can see the wire in the eca without touching the lesion the right hand side now this is the measurements for this 10 how much we are going to cover we are trying to cover with the length of the strength with the tapering string entire blocks and lesion this is a navigation of the wire for the stem and this is the placement of the stem now most of the lesions after the curvature is covered and the origin of the achiness is also covered now through the stent without doing anti-plastic just pass the wire across and this is the theta second catheter for the filing passing across solution step by step without disturbing the state and we reach the repeaters and cervical and which is corrupted this is the angiogram from the peter's character and proceeded the 3-d angiogram for measurements and planning for the aneurysm coil you can note that some daughter blood on the right hand side film it could be a possible uh leaking site which is possible daughter block is always indicative of a synthetic leak so there is a daughter blow and the complex working in the capital pca so we had a measurement of 7.2 in the 6.1 5.8 and the people pca is actually arranging from the necromancer this is the aneurysm pointing step-by-step they're difficult because the overlapping vessels so find a walking angle like this and the step-by-step this is a framing and you can see the coil on the top the right hand side now this is the cost of city angiogram so in the complete opening of the stent this is the coil on the top and it is fully open stem covering the lesions you can see the plaques by the side of the stench this is the cost of ct other than the old electron in fact nothing new issues were there but we shouldn't have some pa like symptoms again maybe the metal interface so i had to change the antiplatelet from properly to the lord and then see and used terminal happen for few days she settled down in her symptoms and she is on all of six months she is still six months now uh asymptomatic which usually requires further flow for the other vessel diseases because already other sinuses still existing now coming to literature these are very rarely reported but the series shows most of them has managed differently and always the distinction making makes the complication seen most of the this is a few studies which actually had a higher number i just wasn't there a lot of studies this is actually by park ital they had uh done single stage procedures their 17 cases were there half they did surgery surgical management as well as intervals only two complications were there due to same thrombosis but most of the patient had a very good results so they recommend uh single stage paper tissues this is another study they left alone this is by korean study they left alone was more like symptomatic undocumented aneurysms and only corrupted revasculation was done but their but however the potential risk of rupture is remaining if you treat and reverse place and increase the flow through that particular battery is another study supporting from the single stage treatment from turkey then another study similarly this actually a case report showing he had an experience of a rupture after treating the carotid sinus aloe because we increase the drawing with the pressure creation diet with the structure of the animals so to conclude controlling discretion so we know it is rare in the presentation we have a concomitant disease of stenosis and aneurysm so it is reported most of the series is between 2.8 and 5 and different studies have managed differently but that they have not still have a victim to manage like this but adequate planning is very important you treat both in one session as the best report i mean best results without much complications so finally to control single stage treatment is a safe and effective method it's properly planned and gives the best results thank you for your patient listening thank you dr srihari excellent demonstration of the therapeutic there so the case open for discussion so one thing i've learned from your case is when there's a difficulty in decision making do an online pony polling you'll get the answer any difficulty in decision making from the audience do an online polling with the ccs members you will get the correct answer most of the time as exemplified in today's online poll i think all the times he got the lead on how to proceed so the case open for discussion one interesting question dr c harry i have seen your work i have been closely following your activities uh suppose this particular patient had aneurysm elsewhere i mean though it is not in the same circle that i think there was a right left labeling problem in your presentation uh you started off saying that it was the stenosis as well as the aneurysm was on the left side but i saw some slides mentioning right corrupting or oh sorry it's in the left side only there are quite a few slides putting it on the right side so i was wondering so basically it was a left-sided carotid finances and a left-sided peacock so tackled it in the same city all right so if suppose the aneurysm is there incidentally detected on another circuit may be vertebral or say opposite corrupted then then they i think the same thing should be followed because i have had similar or no case like that uh because when you drink the corrupt synonymous so antiplatelet and leaving the aneurysm and with the endovascular sciences develop so much minimally invasive you can handle it better to do it off because if the inflation rate has a rupture then it is catastrophic yeah yeah yeah i believe then another of course we also been following papers on hemodynamic alterations in these people you see the people who develop these aneurysms usually have a altered pattern of flow because the lamellar flow is gone multiple stenosis down the line proximally causes altered hemodynamic properties of the blood giving rise to focal wall abnormalities giving rise to of course aneurysms so when you correct it with an increased flow normally nothing should happen but then as the paper which you mentioned 1984 where they had a catastrophic rupture after the intervention is always a warning sign and as you said people who are on anti-platelets for whatever reason if they have detected aneurysms whether to go ahead or not the option should be of course left to the patient but with the sound counseling from the literature so that is our duty as neurosurgeons to educate the people approaches and performance of both thank you dr srihari excellent case i mean with good outcome without any complications of the procedure uh dilatation of the stenosis as well as the coiling of the aneurysm uh needs uh proper follow-up fitting every uh [Music] the department of technology with a unique way of uh detecting and treating good evening everyone first of all i'd like to thank the coaching clinical society for giving me this opportunity to present on this esteemed platform i'd also like to thank dr rahn for the guidance and support so with this moving on to the presentation [Music] [Music] so i'll be presenting a case of a 32 year old male who presented to us with complaints of diminishing of vishnu and dry tie for two days so he was apparently normal two months back uh after which he noticed yellow discoloration coloration of his eyes as well as king of neck and tongue to have elevated bilirubin levels and he was diagnosed with alcoholic hepatitis and chronic liver disease without hypertension on october 2021 who was started on yslan 40 mg od weekly tapering for a 28 day course and while during this immunosuppressive therapy he developed high grade fever with chills and was readmitted in the same hospital the blood investigations were suggestive of an infective etiology and the blood culture yielded kepsiela species and he was started on systemic antibiotics iv mirropinum one gram a bd and two days later during this afternoon's day only he developed diminution of krishna's right eye it was not associated with any pain redness photophobia flashes of lotus he was referred to amrita for further management past yesterday he was a chronic alcoholic and now diagnosed with chronic liver disease reported hypertension and is currently on wise non-tendons there is no significant family in your personal history apart from ignorance general clinical examination was within normal limits systemic examination the gastrointestinal system sold hepatomercally and other systems were within normal limits coming to the ocular examination the vision in the right eye was less when compared to the left eye but the best corrective activity in right eye was six nine and left eye was six six and the intraocular pressures were normally in both eyes 13 and 40 millimeters of mercury in right and left eyes respecting extraocular movements moments and coming to the dilated fundus examination with the indirect ophthalmoscopy dilated examination was uh showing a clear media with a normal disc with well-defined margins and vessels was normal the macula was unaffected explaining the good visual activity and also inferior to the disc there was a retinitis lesion there was a yellowish puffy lesion with ill-defined margins this is a part of depletion and there were surrounding hemorrhages it was suggestive of an uh infective retinitis lesion also the left eye the dilated fungus examination of the left type is within normal limits so in this clinical setting of a person of a patient with a chronic liver disease who was immunosuppressed currently with klebsiella sepsis and was found to have a active retinitis lesion the probable diagnosis will be an endogenous end of thalamites secondary to klebsiella the investigations also showed suggestive of an infective etiology the blood industry blood protein the total count was raised it was about 13 000 and the crp level was also raised it was 11 11.5 also their lft liver function tests were deranged and uh coming to the management we did a victories biopsy and the sample was sent sent for gram smear ko its miran culture and uh we gave an intravetrial injection of a with the broad spectrum coverage that is vancomycin anamic acid was given and also we started on systemic we already he was already on systemic antibiotics we continued the systemic neuropenem we added on topical antibiotics and topical anti-inflammatory agents as well as psychophysics were at and the gram stain and koa smear came out to be negative after two days after the injection we reassess the patient and his um and his vision his uncorrected visual acuity had improved and also the patient was also symptomatically better uh and since he was responding to the treatment we continued the intravitreal injections and after three doses of intravetrial injection of vancomycin and amicus his visual activity was coming to six by six that is he regained his poor vision so he here we have a 32 year old male with alcoholic hepatitis chronic liver disease and bottle hypertension now admitted with klebsiella sepsis and endogenous endothelin and he was treated with intravetrial systemic and topical antibiotics and he responded well to the treatment with the restoration of six by six vision at the time of discharge so uh endogen endothelmitis it's a intraocular inflammation affecting the inner cores of the eye that is the carotid as well as the retina with progressive vitreous inflammation this endogenous this endothelmitis can be of two types exogenous or endogenous as the name suggests exogenous endothelmitis the causative agent is something that is coming from outside that is it can occur as a complication of uh any ocular surgery or following a penetrating trauma whereas endogenous endothermitis it is due to the hematogenous spread of a pathogen from a distinct infective 4k into the eye and as a result the infection occurs so endogenous endophthalmitis is otherwise known as metastatic endothelmitis and it constitute about two to eight percentage of all cases of endothermics so this endogenous endothelmitis is a life threatening as well as a side threatening condition so the outcome the earlier the diagnosis the better will be the outcome so high index of suspicion should be maintained in all cases of uh sepsis so like that if uh if you are going for a rounds in case of a general practitioner if they are going through the rounds if the patient is having any mild redness or if he is complaining of mild diminishing of vision there should be a suspicion of endothelmitis and urgent after knowledge evaluation should be sought at that time so that we can locate the fundus and we can correlate the findings and if there is any endothelmic we can rule it out and we can treat according so the treatment would be in conjunction with the physician and as well as with the advice of a microbiota uh systemic anti anti-antibiotic therapy is a must and also along with the intravetrial antibiotics as well and vitrectomy in case of a severe ocular inflammation is valid twenty five percent of the cases can be bilateral so this is regarding a study conducted in our department where we assess the clinical profile visual outcome anatomical outcome and survival outcome of patients with indigenous endothelmitis from the year 2009 to 2016. uh in our study the most common distractors was type 2 diabetes mellitus along with it uh hypertension chronic liver disease chronic kidney disease uh patients who are immunosuppressed also contributed to the underlying risk factors and the source of infection was urinary tract infection followed by sepsis which was more common in our study which was in part with other studies also and in some of the other studies pneumonia and liver abscess was a common infection whereas hepatobiliary tract infection was also common the etiological age in blickyology is multifactorial and the causative agent shows an extensive geographical variation in india the study conducted from in our department showed an equal incidence of both bacteria and fungi whereas in india study done by dr sharma showed a gram-positive bacteria having more common more commonly seen than the fungi whereas in north american europe streptococcal and staphylococcus was more prevalent and in east asian regions klebsiella was the most common factor and we have to keep in mind that bacterial endothelmitis has an acute presentation whereas a fungi as a sub accurate presentation and another thing i want to stress is that not always the vitreous samples would deal the positive culture and the culture sensitivity rate ranges from a 40 to 60 percentage in our study we got a specific culture's positivity rate of 63 percent so the pathogens is that as i have already mentioned the infective okay from anywhere in the body it reaches the bloodstream and it reaches the choroid where it multiplies and infiltrates the retina and spread to the vitreous causing the inflammation secondly nitrite is to such an extent that we will not be able to visualize the fundus in such cases we will sort a b scan which is a ultrasound imaging of the eye where we where we will be able to see they pick up the vitriticus of choreoretinal lesions as i have already mentioned coming to the diagnosis diagnostic workup we'll do we'll take a trace sample which is biopsy or victory staff was taken and the victory sample is sent sent for the gram staining and culture of fungus training and culture and other blood investigations to find the 4k in this infection should also be done such as complete blood test differential count bacterial culture fungal culture lft rft and if required a b skin ultrasound will be done from our side and other investigation which is required for the diagnosing of the disease would be done by a nation coming on to the management we will give intravitreal uh as soon as the endogenous endothelmitis is diagnosed we will give an intravitreal injection with uh uh which has a coverage of broad spectrum coverage that is if you are suspecting a bacterial endogenous end of telomeres will get vancomycin with ceftacidim or amicus in and if we are suspecting a fungal etiology we will be giving an amputation b or reconnaissance so we will do the intraventral injection in such a way that it is done in an aseptic precaution with a cc syringe and a thirty gauge needle we via the pass planner root will enter into the bit trace and will give the injections so as soon as the uh indigenous endothelial matrix is diagnosed we will give the intravitreal injection and we will assist the response to the treatment after 24 hours if the patient is responding to the treatment we will continue with the interventional injection uh till the lesion heals and if the patient is not responding to the treatment we'll resort to an urgent vitrectomy also if the initial presentation is very severe very severe inflammation is there and the questions mission is very less at that time also we will resort to and retractably along with the intravetrial antibiotics systemic antibiotics are also a must so uh in my case which i just presented the patient was lucky enough to get a visual outcome of 6x6 at the time of discharge but that is not always the case so in our study conducted uh the patient who had a poor vision at initial presentation they also had a poor vision at the final presentation that is at the follow at the final discharge time they had a poor vision about in the study we we analyzed about 22 patients most of them about 16 percentage of 16 people had a prohibition at the time of discharge and also if uh the prohibition was such an extent that about six percent six per percentage of them had no perception of life during the time of discharge and about four for four people the infection spread it to such an extent that that end of telemate is moved on to a pan of the almightys and as a result we had we were left with no choice but to eviscerate die that is removal of the eye should be done so as to prevent the infection respect to the brain so other poor prognostic factors include coefficient of presentation culture positivity functionology eyes with bilateral involvement and in immunosurface so the take home message is uh all immunocompromised patients are the patient with sepsis if they present with any acute decrease in vision pain or redness and urgent ophthalmology evaluation with dilated fundus examination should be sought and once endogenous endothermitis is diagnosed a prompt treatment with individual antibiotics antifungals with or without vitrectomy based on severity of inflammation should be done and the patient should be started on systemic antimicrobials if there is any delay in presentation or treatment the patient not only will lose the vision but also they can lose the eye which significantly add to them well thank you dr mira thank you for that elucidation of the treatment philosophy with the direct intraventral injection to save the eye and you had a good result a couple of questions from my side i was closely following your case and you had diagnosed it to be due to metastatic spread of the bacteria from somewhere in this this patient was not an anti diabetic no this patient was not diabetic so yeah yeah so very strange report because usually usually they get the cultures of step but in these patients where you get klebsiella either they have to be normally i mean from what i gather is normally they are either diabetic or immunocompromised so this patient was neither a diabetic nor immunocompromised then the question is where where is the source from where this patient got the klebsiella from literature says of course it is usually in these people it is but i presume that he was already investigated and liver abscess was ruled out is it so so there was uh there was not there was no liver abscessor but uh probably if that liver infection might be only the forecaster so anyway because quite a serious resistant organism in the hospital setting to get that infection uh source tracing could your particular case it probably spread through the posterior circulation that is why giving rise to the endocrine that is in the posterior chamber normally these intravitreal injections you do it's a very high risk procedure i believe and you would have taken a lot of concern before each injection uh mom what type of complications you normally encounter in intravitreal injections which the audience should be aware of so the patient can have pain uh the hemorrhage then um chance of infection is also there in um introverted injections yeah retinal detachment how often do you see because you know in the procedure you mentioned that you took out some vitreous and then injected the antibiotic so every time this patient did not have these procedures are very high risk procedures and consent separate set of instruments should be used to prevent cross separate injection syringes for each eye because there is an infection from the hospital it should not affect bone dye so interesting which quadrant you were using actually to put the which quadrant of the eye like temporal [Music] is a very common procedure yeah intervital injection is a very common procedure about 25 000 injections happen in india every day but most of these injections are targeted towards vascular retinal diseases like diabetic retinopathy age-related macular degeneration and retinal vein occlusion etc whereas this particular i mean [Music] antibiotics if you let the infection continue you are going to lose the eye and maybe if the infection breaks out through the sclera it may go into the brain and you may actually lose the life also so in the risk benefit analysis in an infection injection is uh you know not at all a risk involved in in the injection problem and amount emotion even a very minuscule amount which is put in 5 ml you know iv for for cancer it's about 4 ml 3 times a day so we are putting 0.05 ml in the diet but even that can have a little bit because the people whom we are doing this treatment are actually very old diabetics long-term kidney problems all those problems are there that is the reason so so recent that is a that is a that is a contraindication the other contra the other problem which can occur with an intraventral injection is always an infection so you give an injection there is an opening within the eye and so if some if some dirt or bacteria or something can go inside through that opening it can cause an infection so post injection may be one day people should be a little careful you should not just put water from somewhere else i think none of the pictures were seen here i mean actually there was a huge large white yellowish retinitis which completely disappeared with three injections and it would have been a real spectator somehow yeah interesting case because you see the patient had a systemic problem with a local manifestation he was a chronic liver disease patient with a systemic septicemia because and blood culture developed glypcella and as a result of that septicemia he developed this bacteria from the root race so i believe majority of the i practice in india is you know standalone eye hospitals so my question was whether such cases can be managed in a standalone high hospital or it requires a peculiarly placed eye department like in amrita where the support of other departments also is there for a composite management of such high risk so that's an excellent question so uh the type of cases that go to a stand-alone eye hospital is a lot different from the type of cases which go to a multi-speciality hospital like um even regarding the endothelius now let me tell you the type of endogenous endothelmitis which goes to a standalone eye horse this is a sufficient deficiency it must have entered into the circulation and went into die or something like that so this guy is not in sepsis now he walks and come to the hospital to a standalone eye hospital probably may get a introverted injection or systemic antibiotics generally now the practice in most of the standalone eye hospital is that if you require to give intravenous antibiotics for maybe more than one or two days it is better to refer them to a hospital like amrita where all these specialties are available because tomorrow you don't know whether it will go into the brain also that problem is there the people who come to us in our department are probably those people who have actual sepsis and uh also multiple infections are there maybe in the kidneys maybe in the gi tract maybe a pneumonia lung abscess liver abscess something like that correct so those are the patients who come to us so there's a difference yeah yeah excellent excellent i appreciate that because traditionally we see i as a standalone you know service most of the hospitals but these cases are particularly poised to be well tackled as you said by departments which have a in-house multi-speciality support and the patient did well congratulations so [Music] any more questions from the audience uh let me check the comment section uh not many questions now so that brings us to the end of the amrida institute uh society 2021 excellent cases uh starting off with pediatric neurology with a diet therapy therapeutic caffeine then diagnostic equipment about the importance of educating the people about the hazards of naturopathy and its complications and neurosurgery department showing its clinical prowess in doing endovascular procedures and last from the department of thermology where a systemic complication with a local manifestation in the eye was excellently managed with intravectorial injections with a very good outcome so all the cases were excellent and as usual as expected from amity the quality of the case presentations were very high and i thoroughly enjoyed going through and moderating the session of course it took i think two days for me to study these cases carefully it was really interesting audience must also have learned a lot so any closing remarks from amazon uh yes sir uh good evening uh on behalf of from the time dr nithya so we have come to the end of this session and uh hope all of you have enjoyed it too uh first of all i would like to thank all the speakers for this uh enlightening and excellent presentation and also for finishing on time uh it was really an eye opener thank you once again uh also i would like to thank dr subramaniam sir for excellently uh moderating the session and for summing it up uh last but not the least i would like to thank each and everyone who is present here in the audience and also the netflix team for making this event a successful one thank you one and all

BEING ATTENDED BY

Dr. Darius Justus & 198 others

SPEAKERS

dr. Suma Balan

Dr. Suma Balan

Consultant Pediatric Rheumatologist, Amrita Institute of Medical Sciences

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dr. Soumya Jagadeeshan

Dr. Soumya Jagadeeshan

Consultant Dermatologist, Amrita Institute of Medical Sciences

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dr. N R Sreehari

Dr. N R Sreehari

Consultant Neurosurgeon Division of Vascular and Endovascular Neurosurgery Amrita Institute of Medical Sciences

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dr. Vaishakh Anand

Dr. Vaishakh Anand

Consultant Pediatric Neulorogist, Amrita Institute of Medical Sciences

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dr. Mira Nair

Dr. Mira Nair

Consultant Ophthamologist, Amrita Institute of Medical Sciences

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Subramaniam P

Dr. Subramaniam P

Lead Consultant Neurosurgeon at RENAI MEDICITY

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dr. Vasantha Nair

Dr. Vasantha Nair

Clinical Professor, Centre for Endocrinology and Diabetes, AIMS

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dr. Nithya Abraham

Dr. Nithya Abraham

Dept of Endocrinology, Amrita Institute of Medical Sciences

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dr. Rehna Rasheed

Dr. Rehna Rasheed

Consultant Ophthalmologist, Amrita Institute of Medical Sciences

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dr. Gopal S Pillai

Dr. Gopal S Pillai

HOD of Opthalmology, Amrita Institute of Medical Sciences

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dr. Suma Balan

Dr. Suma Balan

Consultant Pediatric Rheumatologist, Amrita I...

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dr. Soumya Jagadeeshan

Dr. Soumya Jagadeeshan

Consultant Dermatologist, Amrita Institute of...

+ Details
dr. N R Sreehari

Dr. N R Sreehari

Consultant Neurosurgeon Division of Vascular ...

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dr. Vaishakh Anand

Dr. Vaishakh Anand

Consultant Pediatric Neulorogist, Amrita Inst...

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dr. Mira Nair

Dr. Mira Nair

Consultant Ophthamologist, Amrita Institute o...

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Subramaniam P

Dr. Subramaniam P

Lead Consultant Neurosurgeon at RENAI MEDICIT...

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dr. Vasantha Nair

Dr. Vasantha Nair

Clinical Professor, Centre for Endocrinology ...

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dr. Nithya Abraham

Dr. Nithya Abraham

Dept of Endocrinology, Amrita Institute of Me...

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dr. Rehna Rasheed

Dr. Rehna Rasheed

Consultant Ophthalmologist, Amrita Institute ...

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dr. Gopal S Pillai

Dr. Gopal S Pillai

HOD of Opthalmology, Amrita Institute of Medi...

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