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#1. A 15-year-old boy has been having recurrent hospitalizations for infections, since 2 years of age. After a detailed evaluation, a diagnosis of Kartagener’s syndrome was made. Which of the following features is not a component of the triad seen in this condition?
Male infertility is typical in Kartagener syndrome, but not a component of the triad. Kartagener’s syndrome is primary ciliary dyskinesia characterized by the classical triad of:
- Situs inversus
- Chronic sinusitis
- Bronchiectasis
Primary ciliary dyskinesia (also called immotile cilia syndrome) is an autosomal recessive disorder affecting ciliary motility. It occurs due to ultrastructural defects in the dynein arm of cilia. This causes the retention of secretions due to a failed mucociliary clearance mechanism. Clinically, this manifests as chronic sinusitis and recurrent infections that ultimately lead to bronchiectasis.
As ciliary function is necessary to ensure proper rotation of the developing organs in the chest and abdomen, its absence, will lead to situs inversus or a partial lateralizing abnormality.
Male patients with this condition tend to be infertile, due to asthenospermia (immotile spermatozoa due to impaired sperm flagella function).
The Carrageenan-induced pain model is also called the Carrageenan-lnduced Paw Edema model.
A nonantigenic phlogistic polysaccharide derived from red seaweed, carrageenan is frequently added to processed foods as a thickening, stabilising, gelling, and emulsifying agent.
#2. Which of the following types of pain stimulus is associated with the Carrageenan-induced experimental pain model?
The said model is a well-known model of acute inflammation. It is employed to evaluate the antiinflammatory properties of a variety of synthetic and natural substances.
The activation of the complement system and inflammatory mediators is caused by the sulphated sugars found in carrageenan.
Carrageenan is injected subcutaneously into the plantar surface of the rat paw to cause inflammation. This process results in temporary inflammation and acute swelling, which peaks 3 to 5 hours after injection and subsides in 24 hours.
Postcapillary venules dilate due to the action of carrageenan, causing inflammatory cells and fluid to exude. During this process, a number of proinflammatory mediators are released. The cyclooxygenase pathway’s activation is commonly associated with the carrageenan model. A biphasic curve represents the edema caused by carrageenan.
Part of the initial phase of inflammation caused by carrageenan is attributed to injection trauma and the release of acute phase mediators, particularly bradykinin, histamine, and serotonin. The second phase of carrageenan-induced inflammation, which happens about three hours after carrageenan is added, is mostly caused by prostaglandins.
#3. A chronic alcoholic patient came to the emergency with pain in the epigastrium radiating to the back and recurrent vomiting. On examination, guarding was present in the upper epigastrium. The erect chest X-ray was normal. What is the next step? ? The clinical scenario of the patient presenting with abdominal pain, recurrent vomiting, and upper epigastric guarding in a chronic alcoholic is highly suggestive of acute pancreatitis.
The normal erect chest X-ray indicates that there is no pneumoperitoneum (effectively ruling out perforation). The next step is to send blood samples for serum lipase levels.
While contrast-enhanced computed tomography (CECT) of the abdomen (option D) is the best investigation to rule out a case of acute pancreatitis, it is not the next step after an abdominal X-ray.
Acute pancreatitis is often caused by gallstones (70%) or alcoholism (25%). The cardinal symptom is acute-onset severe pain in the upper quadrant of the abdomen. The patient usually presents in shock (hypotension and tachycardia) and tachypnoea. Some may also present with signs of bleeding into the fascial planes leading to discoloration of the sites involved:
- Cullen’s sign: Around the umbilicus
- Grey Turner’s sign: Flanks
- Fox sign: Inguinal region
- Bryant’s sign: Scrotum
The diagnosis is often clinical with a laboratory diagnosis of serum lipase preferred over serum amylase.
The severity of the acute pancreatitis is assessed using the Ranson and Glasgow scoring system (23 at 48h of onset of pain). APACHE, SOFA, SAPS, and MODS can also be used to assess the severity of pancreatitis in intensive care (ICU) settings.
Pancreatitis is managed conservatively with initial nasogastric drainage followed by intravenous fluids, analgesia, and frequent monitoring of vital signs, urine output, and blood gases.
Other options:
- Option A: Upper Gl endoscopy is performed by passing a flexible endoscope and is the best method for examining the upper gastrointestinal mucosa. It doesn’t help us diagnose pancreatitis.
- Option B: The alcohol breath test is used as a screening test to measure the concentration of alcohol in a person’s breath, but doesn’t help us diagnose pancreatitis.
Causes of Acute Pancreatitis:
- Gallstones – most common
- Alcohol
- Post-ERCP (Endoscopic retrograde cholangiopancreatography)
#4. Which of the following is the best line of treatment in a 3-year-old child presenting with a recent onset of 15-degree accommodative esotropia?
The best line of treatment in accommodative esotropia is a refractive correction. Esotropia for distance is corrected by the treatment of hypermetropia: convex glasses. Esotropia for near is corrected by 3DS lens.
Algorithm for the management of accommodative esotropia:
- R: Refractive correction: Glasses/Miotics
- O: Orthoptics/ Occlusion: for amblyopia
- O: Operative correction: for nonaccommodative component
- P: Prism correction: for remaining error