Rare Scar Sarcoidosis: A Dermatologic Masquerader

Infiltration of sarcoid granuloma in old cutaneous scars is one of the uncommon cutaneous manifestations of sarcoidosis. Here we report the case of a 32-year-old female who presented with swelling and irritation in a 9-month-old appendicectomy scar. An incisional scar biopsy was done and it revealed non-caseating granuloma. On query she had inflammatory polyarthritis and persistent dry cough for last two months. High resolution CT (HRCT) revealed right paratracheal, both hilar, paraaortic, and subcarinal lymphadenopathy with pulmonary nodular densities in both lung fields. FNAC from mediastinal node revealed non-caseating granuloma consistent with sarcoidosis. Successful regression of cutaneous inflammation was achieved using a course of oral steroids, hydroxychloroquine and methotrexate. The incidence of scar sarcoidosis is rare and therefore not well-understood. However, inflammatory alterations in preexisting scars may be important indicators of disease onset. J Enam Med Col 2020; 10(2): 122-125

Hirschsprung’s Disease: Diagnosis and Management

Hirschsprung’s disease (HD) is a rare genetic congenital defect of intestine causing failure of migration of parasympathetic ganglionic cells in some definite part of intestine, resulting in functional intestinal obstruction. It commonly involves rectosigmoid region of colon but other parts of colon or total colon, even small intestine may be affected. Incidence is 1/5000 live births. It is one of the common pediatric surgical problems and 2nd most organic cause of constipation. Symptoms may be evident from 1st day of life. About 90% infants with Hirschprung’s disease fail to pass meconium in 1st 24 hours of life. About 80% HD cases are diagnosed in early few months of life and present with abdominal distention, constipation, poor feeding, vomiting etc. HD enterocolitis is a devastating condition related to mortality. HD may be associated with some congenital anomalies and syndrome. High index of suspicion is the main key to diagnosis. Radiological investigation supports the diagnosis and rectal biopsy for histopathology is confirmatory. Although it is a surgical problem, physician can play a key role in early diagnosis and thus help to prevent HD enterocolitis-related mortality and restore near-normal life. J Enam Med Col 2020; 10(2): 104-113

An Unusual Cause of Efferent Loop Obstruction

Efferent loop obstruction is a very rare post-gastrectomy obstruction that can occur following Billroth-II or Roux-en-Y reconstruction. Here we report a case who underwent gastrojejunostomy for gastric outlet obstruction 30 years back and now developed efferent loop obstruction due to phytobezoar. The efferent loop obstruction was successfully resolved by laparotomy. J Enam Med Col 2020; 10(2): 118-121

A Female with Evans Syndrome Presented with Pancytopenia

Evans syndrome is an uncommon haematological disorder characterised by autoimmune haemolytic anaemia (AIHA), immune thrombocytopenia (ITP) and/or immune neutropenia. It may occur in all ethnic groups, all ages and has no sex predilection. The direct antiglobulin test (DAT) is almost invariably positive. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. Corticosteroids and/or intravenous immunoglobulin (IVIG) are the most commonly used first line therapy. Here we report a case of a female who presented with severe shortness of breath, palpitation and low grade fever and on examination she was found severely pale and mildly icteric. Her CBC and PBF showed pancytopenia. Indirect bilirubin and LDH were raised and direct Coomb’s test was positive. She was labeled as a case of Evans syndrome and responded to oral prednisolone. On subsequent follow-up her haematological profiles remained normal. J Enam Med Col 2020; 10(2): 114-117

Covid-19 — An Epic Pandemic is on the Loose!

not available J Enam Med Col 2020; 10(2): 64-68

Non-Diabetic Renal Disease in Type 2 Diabetic Patients with Nephropathy

Background: In diabetic patients a good proportion of nephropathy is due to nephropathy other than diabetic renal disease. The detection of superimposed primary nondiabetic renal disease in diabetic patients has an obvious prognostic and therapeutic importance. Objectives: To find out the proportion of diabetic subjects suffering from nondiabetic renal disease (NDRD) and to describe histological varieties in appropriate group. Materials and Methods: This crosssectional study was done in Department of Nephrology, Dhaka Medical College & Hospital, Dhaka from August 2015 to October 2016. Total 37 type 2 diabetic patients were selected. Renal biopsy was done and four cases were excluded due to inadequate sample. Tissue was sent for histopathology and direct immunofluorescence (DIF) examination. On the basis of histological diagnosis of biopsy reports patients were divided into three groups. Group I: Isolated NDRD, Group II: NDRD superimposed on diabetic nephropathy (mixed lesion) and Group III: Isolated diabetic nephropathy (DN). Each patient was evaluated for retinopathy from Ophthalmology department. Based on the presence or absence of retinopathy 33 patients were again divided into two groups. Group A includes patients with diabetic retinopathy (DR) and Group B includes patients without diabetic retinopathy. Results: NDRD was found in 57.6% cases, NDRD plus diabetic nephropathy (DN) in 21.2% and isolated DN in 21.2% cases. In Group A (patients with DR) NDRD, DN and mixed lesion were present in 7 (41.2%), 5 (29.4%) and 5 (29.4%) cases. In Group B (patients without DR) NDRD, DN and mixed lesion were present in 12 (75%), 2 (12.5%) and 2 (12.5%) cases respectively. p value (0.189) was not significant. Conclusion: Kidney disease other than diabetic nephropathy can occur in type 2 diabetic patients. In this study NDRD was found in high frequency. Lack of retinopathy is a poor predictor of nondiabetic kidney disease. Therefore, renal biopsy should be recommended in type 2 diabetic patients with risk factors of NDRD for accurate diagnosis, prompt initiation of disease-specific treatment and ultimately better renal outcome. J Enam Med Col 2020; 10(2): 73-78

Jejunogastric Intussusception: A Rare Complication of Gastric Surgery

not available J Enam Med Col 2020; 10(2): 126-129

Study on Menorrhagia: Correlation with Fibroids

Background: Excessive menstrual bleeding called menorrhagia is a common presentation of females seeking medical attention. Normally there is considerable variation in menstrual cycle length, duration and flow. Objective: To find out the assocation of fibroids in patients presenting with menorrhagia. Materials and Methods: This cross-sectional prospective study was done from January to June 2013 among the female patients admitted in the department of Gynaecology & Obstetrics in Dhaka Medical College & Hospital. Patients presented with the complaints of menorrhagia and treated by surgical management were included. Results: Total 96 patients were included. The age range was 28–49 years with mean age 41.08 ± 5.174 years. In 92 (46.5%) patients excessive per vaginal bleeding was noted. Pain during menstruation was another major complaint (45, 46.5%). Lower abdominal heaviness was reported in 32 patients (16.2%). In about half of the patients (49%) uterine fibroid was diagnosed. In 29 patients (30.2%) adenomyosis was the finding. Out of 47 fibroid cases 39 (83%) had per vaginal bleeding history. Only 10 patients without fibroid experienced pervaginal bleeding. Chi-squared test was done to see whether there was any association between these two variables and the result was highly significant (p<0.001). Conclusion: As medical treatment is disappointing and surgery is the mainstay of treatment of menorrhagia caused by fibroids, diagnosis should be confirmed by different imaging techniques. Advancement in the field of imaging like saline infusion sonohysterography and hysteroscopy helps greatly to diagnose submucous fibroids and save patients from undue prolongation of medical treatment. J Enam Med Col 2020; 10(2): 99-103

Reviewers in this Issue Vol 10(2)

not available J Enam Med Col 2020; 10(2): 132

Outcome of Varus Derotation Osteotomy for Containment of Femoral Head in Advanced Perthes Disease

Background: Legg-Calve-Perthes (LCP) disease, or idiopathic avascular necrosis of the femoral head occurs during early childhood and is caused by impaired circulation in the femoral head. Varus derotation osteotomy (VDO) was described over half a century ago, and is now a popular method for the operative treatment of Perthes disease. Objective: To find out the clinical and radiological outcome of varus derotation osteotomy for containment of femoral head in advanced Perthes disease. Materials and Methods: This observational study was conducted in the Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka from March 2015 to September 2017. Total 20 cases of advanced Perthes disease were enrolled. Pre- and post-operative period were evaluated by interview and clinical examination by using a semi-structured questionnaire. Demographic and clinical information were recorded. All patients had a pre- and post-operative x-rays. We used visual analog scales (VAS) for scoring pain; Wiberg’s central edge angle, epiphyseal extraction index, neck shaft angle and Larson (Iowa) hip score were used to assess the outcome of VDO. Comparison of continuous variables between the two groups was made with Student’s t-tests. Comparison of proportions between Herring groups B and C were made with chi-square tests. p<0.05 was considered as significant. All the data were compiled and sorted properly and the quantitative data were analyzed statistically by using Statistical Package for Social Sciences (SPSS 22.0). Results: In the present study, mean visual analog scale (VAS) score and epiphyseal extraction index (EEI) were significantly (p<0.001) lower in Herring Group B in comparison to that of Group C, but mean WCEA, NSA and HLS were significantly (p<0.001) higher in Herring Group B in comparison to that of Group C. Conclusion: Varus osteotomy gives good results in children aged 6–12 years who do not exhibit any femoral head deformity or flattening, especially those with good containment in abduction in advance Perthes disease. J Enam Med Col 2020; 10(2): 79-85