Tuberculosis of the Parotid gland

Recently I came across a case report on tuberculosis of the parotid gland by Garg et al. published in Lung India. Although rare, parotid tuberculosis should be considered in the differential diagnosis of parotid swelling that is slowly progressive. The diagnosis of parotid tuberculosis requires a high degree of clinical suspicion to avoid unnecessary surgery.

Parotid tuberculosis: Features

Parotid gland is the largest salivary gland in the body, draining in the oral cavity via Stenson’s duct opposite the upper second molar tooth. The swelling in case of parotid tuberculosis is a slowly progressive one, toothache and trismus may also be present.

Discharging sinuses may also be present over the swelling in case of parotid tuberculosis. There may be associated enlargement of the lymph nodes of the neck. Facial nerve involvement should also be noted. Fever may also be present. History of tuberculosis should also be worked out.

Infection of the parotid gland by M. tuberculosis causing parotid tuberculosis may occur directly through the oral cavity or it may be a blood borne infection from distant foci or via the lymphatics from the oral cavity.

Investigations

Hemoglobin levels may be decreased. This may be due to the chronic infection or it may be due to malnutrition. There may be predominance of lymphocytes in the blood.

Imaging: High resolution ultrasonography of the parotid region is the initial investigation of choice. This is important as it provides an index of suspicion. In another case report by Kundu et al. preoperative diagnosis of parotid tuberculosis was not done as this investigation was not performed. The diagnosis as made on subsequent histopathological examination of the excised lesion. Ultrasonographically, parotid tuberculosis can be divided in to parenchymal type and periparotid type.

Chest X-ray should also be done to look for any pulmonary lesions.

Tests for Tuberculosis

• Mantoux test – it is not diagnostic.
• Sputum for presence for acid fast bacilli.
• ELISA for anti tubercular IgM and IgG.
• FNAC with Ziehl-Neelsen staining for acid fast bacilli.
• Histopathological examination.

Treatment

Multidrug therapy for 6 months with 4 drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) in the intensive phase and 2 drugs (Isoniazid, Rifampicin) in the continuation is the treatment of choice.

The authors also state that 3 (Isoniazid, Rifampicin, Pyrazinamide) drugs in the intensive phase and 2 drugs in the continuation phase may also be adequate as this is a paucibacillary form.

Links

• Parotid Tuberculosis
• Tuberculosis of Parotid gland: A rare clinical entity.

Otosclerosis: Role of infection and genetics

Otosclerosis is the commonest cause of non-suppurative conductive hearing loss in adults. It is a disease of the otic capsule characterized by vascular spongy bone formation causing fixation of the stapes and progressive conductive deafness. It is characterized by progressive hearing loss which is conductive in type, painless and often bilateral. An otosclerotic patient can hear better in noisy surrounding, the phenomenon being called paracusis willisii. Tinnitus and vertigo may also be associated with otosclerosis.

Schwartze sign in otosclerosis

The etiology of otosclerosis is not clear. Several factors like heredity, sex, race, metabolic disorders and endocrinal causes have been suggested.

Measles virus infection is considered to be associated with the development of otosclerosis. Presence of chronic inflammation have been shown in the otosclerotic foci and measles virus N, P and F protein have been shown to be present in the cells of the otosclerotic foci. Measles virus RNA has also been demonstrated in fresh frozen otosclerotic tissue. It has been hypothesized that the infection of the middle ear mucosa occurs via the Eustachian tube. The measles virus subsequently infects the bony labyrinth via the lymphatic or pericapillary space causing otosclerosis.

Genetic factors have also been found to be associated with otosclerosis. Majority of the present epidemiological studies found the disease to be associated with autosomal dominant inheritance. In one study, observing the inheritance of otosclerosis in a multigenerational family, an association was found with the FES-D15S657 region of the long arm of the 15^th chromosome. The gene mapped to this region is aggrecan the major non-collagenous component of the extracellular matrix of cartilage. In another genome wide analysis, variants in the RELN gene was associated with otosclerosis. The gene identified is in Chr 7q22.1.

These information suggest that apart from a viral etiology, genetic factors are important for the development of otosclerosis. The genetic factors and infection may be acting together to produce the final disease.

More information - 

• http://hmg.oxfordjournals.org/content/7/2/285.abstract
• http://content.karger.com/ProdukteDB/produkte.asp?Doi=98676
• http://www.cell.com/AJHG/abstract/S0002-9297(09)00046-9 

Otitis Media in winter: Acute Otitis Media or Otitis Media with Effusion?

Winter is at our doorstep and with it the incidence of viral respiratory tract infections and allergic conditions of the upper respiratory tract is on the rise. Both these conditions give rise to otitis media by blocking the Eustachian tube and impairing middle ear cavity drainage. This results in fluid accumulation which may  become infected causing acute otitis media. The incidence of otitis media with effusion is very common; almost 90% of children suffer from otitis media with effusion before school age.

Eustachian Tube

Otitis media with effusion may immediately precede an attack of acute otitis media or may follow an attack of acute otitis media. These two conditions need to be differentiated because antibiotic treatment is not always necessary in otitis media with effusion. Unnecessary antibiotic treatment may cause treatment failure and subsequent drug resistance.

Signs and Symptoms	Otitis media with effusion	Acute otitis media
Hearing Loss	Mild-to-moderate	Mild-to-moderate
Earache	Absent	Moderate-to-severe
Tenderness	Absent	Absent
Purulent drainage from ear	Absent	Only after perforation of tympanic membrane
Bacterial infection	Absent	Present
Systemic symptoms  ( fever, malaise)	Present	Present

Otitis media with effusion generally presents with mild to moderate hearing loss, conductive in type and is not associated any pain or fever. It is diagnosed by pneumatic otoscopy in which the tympanic membrane is immobilized. Tympanometry is also a useful investigation. On examination of the infected ear, the tympanic membrane is retracted. Fluid is present behind the tympanic membrane, presence of air bubbles or air-fluid level is pathognomonic. It generally resolves without treatment.

Retracted tympanic membrane

Acute Otitis media is sudden in onset, associated with pain in the affected ear and hearing loss, conductive in type is present. System symptoms such as fever are present. On examination, the tympanic membrane is red and bulged; rupture of the tympanic membrane provides relief to the symptoms.

Red, bulged tymanic membrane in AOM

 More information:

• http://www.aap.org/healthtopics/earinfections.cfm 
• http://cme.medscape.com/viewarticle/730698

New rules to buy antibiotics

In the wake of the New Delhi metallo - beta - lactamase 1 (NDM 1) hoopla, the Drug Controller General of India has decided to introduce new rules to curb the sales of over-the-counter antibiotics.

Now patients will need to have two copies of prescription for buying a medicine, one copy to be kept with the chemist. What does it mean for the doctors? Do they have to write double prescriptions? These are grey areas and the details are sketchy. Nothing can be said with surety unless the DGCI issues clear guidelines.

The approach is new and hopefully it will reduce the abuse of antibiotics although I have my doubts if this will succeed in reducing the use of over-the-counter antibiotics. Law itself has never been a problem in India, the enforcement of the law is the problem. The failure of the present system is not because of it's inadequacy but due to the fact that no one is enforcing the present drug control laws. When the new regulation comes in effect who is going to enforce it? Unless it is enforced properly it will eventually be rendered useless as the present system.

The DGCI is also planning to introduce a new schedule of drugs called HX.

Do calcium supplements really cause heart attack: Controversy

In a recent study published in the British Medical Journal, researchers found a 30% increase in myocardial infarction (heart attack) with the intake of calcium supplements. Already several other researchers have questioned the validity of the conclusions of the study.

Let us see what the questions raised are.

Firstly, the study included 15 trials, that are 15 different studies, but the caveat is that patient level data was available for only 5 studies. What this means is that direct data was available for only 5 studies, in case of the other 10 studies no direct data was available. But the researchers have based their findings on these other 10 studies also.

The second question that has been raised and which is significant is that there is no linear correlation between the dose of calcium and the incidence of heart attack. This means that increased doses of calcium does not increase the risk of heart attack. Now if calcium really does cause heart attack, the findings should have been opposite, with increased doses of calcium there would have been increased risk of heart attack. This finding seriously contradicts the conclusion that calcium causes heart attack.

Thirdly, out of the 15 trials included cardiovascular outcomes were either incomplete or absent in 7 trials. This means that the data regarding heart attack was either incomplete or absent in 7 of the included studies. Now this is a serious methodological flaw.

Fourthly, the researchers have not mentioned whether there was adequate control for other confounders like smoking or hypertension (increased blood pressure). This is important because smoking or hypertension may them-selves cause heart attack, hence they are called confounders. To explain simply, let us suppose that a smoker is taking calcium supplements and has a heart attack. Now we cannot say that the heart attack was due to calcium supplements because smoking also causes heart attack. Thus the validity of the study can be questioned, as it did not address these issues.

The findings of the study are open to question. We should not adopt a knee-jerk reaction as calcium supplement is a cheap measure to prevent osteoporosis and most Indians are deficient in calcium. The findings need to be validated by further research. In the meanwhile, there is no cause for concern.

Links:

1. http://www.bmj.com/cgi/content/full/341/jul29_1/c3691

2. http://www.bmj.com/cgi/eletters/341/jul29_1/c3691

Problem of arthritis treatment in elderly

My father complained of pain in his right knee about one year ago. Initially he ignored it, thinking it to be due to overexertion but gradually the pain increased in intensity. There was restriction of movement in of the right knee joint. On examination, he was provisionally diagnosed as having osteoarthritis of the knee, confirmed with X-ray. He was prescribed Diacrein tablets and Aceclofenac 100 mg for pain control along with antacids. What happened next highlights the problem of treatment of arthritis in the elderly.

His arthritis was well controlled with medications. But after about 7 months on the treatment, he started feeling shortness of breath when he used the stairs. His blood pressure also spiked. When I examined him, I thought I have heard an ejection systolic murmur. Understandably I was worried. All the bad diagnoses came to my mind. He was examined by a cardiologist, my teacher actually, but he disagreed about the murmur. To establish a diagnosis, an ECG, chest X-ray and echocardiography was performed. Nothing was found. The cardiologist asked to discontinue the Aceclofenac and arranged for follow-up. A coronary angiogram was scheduled to be performed if the shortness of persisted on follow-up. On discontinuation of aceclofenac, my father did not complain of any shortness of breath. Presently, his arthritis is well controlled with acetaminophen (paracetamol).

This small anecdote demonstrates the problem in the control of pain in elderly arthritis patients besides the gastrointestinal problems caused by NSAIDs. Treatment of pain with Non steroidal anti inflammatory drugs (NSAIDs) causes significant cardiovascular problems. Several studies have shown NSAID use in elderly is an independent risk factor for hypertension (links given below). NSAIDs block the cyclooxygenase enzyme, nonselective NSAIDs block both COX-1 and COX-2 isoforms. COX-1 synthesize prostaglandins which are responsible for vasodilation and COX-2 produce prostaglandins which maintain diuresis and natriuresis. NSAIDs, thus may hypertension either by blocking the natriuresis causing sodium and water retention and by blocking vasodilation and production of vasoconstricting endothelins. A careful history taking is therefore of paramount importance while NSAIDs are prescribed to elderly as hypertension is a major risk factor for a variety of cardiovascular problems like myocardial infarction, stroke etc.

Currently there is interest in another novel group of drugs, which are CINODs (Cyclooxygenase inhibiting nitric oxide donators), which have much favourable gastrointestinal profile, and less chance of development of hypertension. As far as I know, at present CINODs are not marketed in India, but the introduction of CINODs will open up a new option arthritis treatment.

Links:

NSAID and hypertension

1.                  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381681/

2.                  http://www.ncbi.nlm.nih.gov/pubmed/9467684?ordinalpos=1&itool=PPMCLayout.PPMCAppController.PPMCArticlePage.PPMCPubmedRA&linkpos=1

CINODs

1.                  http://www.ingentaconnect.com/content/ben/chamc/2006/00000004/00000002/art00004

Naturopathy and Blasphemy

The guiding principles of naturopathy left me shocked. According to the Department of Ayush that promotes naturopathy, bacteria do not cause disease. Do they really believe it? Is Tuberculosis not caused by bacteria? May be they ought to look at the millions of TB bacilli multiplying within the lungs of TB patients, then the truth will dawn on them. I wonder if these practitioners of naturopathy have ever studied biology, leave alone medicine as even a student of class eight will tell you that bacteria causes disease. All their blasphemy can viewed here http://indianmedicine.nic.in/naturopathy.asp.  All diseases are same, as is their treatment is what they claim. May be when they have diarrhoea, they can treat themselves with drugs for constipation, all the treatment are same they say. I bet the result will be spectacular.

Another claim that they make is that acute diseases are our friends. Who in their right mind will make such claim? May be they can tell their philosophy to a patient dying of rabies, tetanus, pneumonia or hundreds of other deadly acute diseases. Makes me wonder what they do when they themselves are affected by so called friendly diseases.

There is a pathetic attempt at trying to impress the visitors by referring to Gandhiji. They don’t realize they are making a logical fallacy of Appeal to Authority, not that it is unexpected of them to make such a fallacy. Gandhiji may have been a virtuoso in many things but a doctor he was not. Only people who don’t have evidence to back up their claims make such attempts.

They also do a bang up job in listing their therapies. Space therapy, mud therapy, magneto therapy? Charged water? Stuff of fairy tales. Where is the evidence? Chromo therapy takes the cake in completely useless therapies. There is not an iota of biological plausibility in their claims.

If one considers that the government always says that there are not enough funds for meeting the basic health care needs of the people, the government expenditure on these completely useless therapies is totally unethical. The government fails to provide basic medicines and equipments to the hospitals because of lack of funds but it is prompt to sponsor these useless therapies. It is high time that the government stops promoting such useless therapies.