Research Connect

Solunke, Dr Hrishikesh

M, Dr Kishor

Digital Journal of Clinical Medicine 
Volume 2 Issue 2 Article 10 
1-1-2020 
A Case of Mixed Anxiety Depression in the COVID-19 Lockdown 
Dr Hrishikesh Solunke 
JSS AHER 
Dr Kishor M 
JSS AHER 
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 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Solunke, Dr Hrishikesh and M, Dr Kishor (2020) "A Case of Mixed Anxiety Depression in the COVID-19 
Lockdown," Digital Journal of Clinical Medicine: Vol. 2: Iss. 2, Article 10. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
A Case of Mixed Anxiety Depression in the COVID-19 Lockdown 
Dr Hrishikesh Solunke, Dr Kishor M  
 
CLINICAL HISTORY: 
A 43 year old male patient from rural area, educated up to Pre-university, electronic technician 
by profession, married and living with his wife and two children, reported to the psychiatry 
outpatient department complaints of tiredness for 3-4 weeks, feeling worried, fearful about 
having a corona infection even without any contact or symptoms. 
The patient expressed that he would feel like sanitizing his hands often since the news of corona 
virus emerged. 
He also reported that watching the news would increase thoughts with sweating, shiver and 
racing heartbeat. These episodes would last for five to ten minutes and would occur once or 
twice a day. 
The patient had visited a local ayurvedic practitioner twice to get investigated and treated as 
acidity for these complaints but symptoms did not reduce. The patient complained of feeling sad, 
off and on due to this, along with a decreased interest, loss of libido and could not carry day to 
day activities. 
He also complained of disturbed sleep, with a delay in initiation of sleep by more than an hour 
and decreased appetite. There was no significant past history, and no history of psychiatric 
illness in the family. 
EXAMINATION AND INVESTIGATIONS: 
General Physical Examination: 
Moderately built and adequately nourished. General physical andsystemic examination was 
unremarkable. 
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Solunke and M: A Case of Mixed Anxiety Depression in the COVID-19 Lockdown
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Mental Status Examination: 
The patient was adequately groomed, cooperative and well oriented to time, place and person. 
He maintained eye contact throughout the interview and rapport was established with ease. The 
patient appeared uneasy and was occasionally fidgeting in his seat.  
The patient’s speech was normal. His thoughts mainly revolved around the fear that he might 
somehow contract COVID-19. He was preoccupied “what if I get” and expressed apprehension 
and worry about his own health and the safety and well being of his family members. 
The patient expressed concern regarding lack of earnings in this period of lockdown and was 
worried about financial troubles in the future. He reported negative thoughts about his health, 
and would often wonder what would happen to his wife and children if something were to 
happen to him.His mood was anxious and depressed. 
There were no history suggestive obsessive compulsive disorder or delusions or any perceptual 
disturbances in the patient, and there were no other positive findings.  
Assessments: 
The Hamilton Depression rating Scale (HDRS) and Generalised Anxiety Disorder-7 (GAD-7) 
rating scale were applied. 
The patient scored 12 on the HDRS, indicating mild depression,and 13 on the GAD-7 denoting 
moderate anxiety. 
FINAL DIAGNOSIS: 
Mixed Anxiety Depression  based on WHO ICD 10 (International Classification of Disorders) 
Criteria : Low or Sad mood, loss of interest or pleasure with prominent anxiety or worry. 
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Symptoms are present most number of days for at least 2 weeks 
TREATMENT: 
Non-Pharmacological: 
The patient was educated regarding COVID-19 infection. He was advised to reduce the amount 
of news exposure as per WHO guidelines and reduce the discussions regarding the same. He was 
taught breathing exercises, and Jacobson Progressive Muscular Relaxation JPMR techniques. He 
was also advised to inculcate a routine during lockdown, a healthy lifestyle, with a good diet and 
regular exercise.  
Pharmacological: 
Tablet Clonazepam  (Benzodiazepine) 0.25mg 1-0-1 and SOS for 1 week. 
Tablet Escitalopram (SSRI)  5mg 1-0-0 for 1 week & review. Increase to optimal dosage for at 
least 3-6months 
The patient was educated about the possible side effects of the medications and was advised to 
come for follow up to the psychiatry OPD after one week. 
DISCUSSION: 
It is important to screen patients for psychiatric conditions during the COVID19 crisis and 
aftermath of the disaster. 
General Health Questionnaire with five questions (GHQ5) is simple tool for health care 
professionals, validated in India. 2 
 
Mental disorders are among the leading causes of non-fatal disease burden in India. 
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Solunke and M: A Case of Mixed Anxiety Depression in the COVID-19 Lockdown
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One in seven Indians is affected by mental disorders of varying severity according to National 
Mental Survey 2015-16, Govt of India. 
The Global burden of disease survey 2017 reported nearly 200 million Indians have a psychiatric 
condition that needs treatment. 45 million have depressive disorder and 44 million have anxiety 
disorder1 (ICMR Collaborated study published in Lancet 2019) 
 
The proportional contribution of mental disorders to the total disease burden in India has almost 
doubled since 1990. Amongst these, the prevalence of anxiety disorders in India in both the 
sexes was 3.3% in 2017.2 
It is important to consider the high existing morbidity in India, when whole population is 
affected by the novel coronavirus disease 2019 pandemic, specific sections of the population will 
be more affected. 
They may be affected by issues including isolation or quarantine, loneliness, socio-economic 
adversities. 
 
People with existing mental health issues, including those with severe mental illnesses, might be 
particularly affected by relapse, disruptions to services, the possible exacerbation of symptoms in 
response to pandemic-related information, increased discrimination and crime against minorities, 
against women, and other trauma. Rural communities might also be affected differently to urban 
communities. Also, people on low incomes, or ones who have a hand-to-mouth existence 
especially in a country like India, face job and financial insecurity, cramped housing, and poor 
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access to basic services and healthcare.3,4,5,6 These are strongly associated with anxiety, 
depression, self-harm, and suicide attempts across the lifespan.7,8 
 
Reports of infectious diseases in the media often use risk-elevating messages, which can amplify 
public anxiety.9 Social media too can lead to a lot of misinformation.10 
Repeated viewing of the media coverage of the disease can exacerbate stress responses, amplify 
worry, and impair functioning.11 
REFERENCES: 
 
1. Shamasunder C. Indian Journal of Psychiatry.1986;28(3):217-219.) 
2. Sagar R, Dandona R, Gururaj G, Dhaliwal R, Singh A, Ferrari A et al. The burden of 
mental disorders across the states of India: the Global Burden of Disease Study 1990–
2017. The Lancet Psychiatry. 2020;7(2):148-161. 
3. Holmes E, O’Connor R, Perry V, Tracey I, Wessely S, Arseneault L et al. 
Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for 
mental health science. The Lancet Psychiatry. 2020; 
4. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and 
how to reduce it: rapid review of the evidence. Lancet 2020; 395: 912–20 
5. Rubin GJ, Potts HWW, Michie S. The impact of communications about swine flu 
(influenza A H1N1v) on public responses to the outbreak: results from 36 national 
telephone surveys in the UK. Health Technol Assess 2010; 14: 183–266. 
6. Lau JTF, Griffiths S, Choi KC, Tsui HY. Avoidance behaviors and negative 
psychological responses in the general population in the initial stage of the H1N1 
pandemic in Hong Kong. BMC Infect Dis2010; 10: 139 
7. Elovainio M, Hakulinen C, Pulkki-Råback L, et al. Contribution of risk factors to excess 
mortality in isolated and lonely individuals: an analysis of data from the UK Biobank 
cohort study. Lancet Public Health 2017; 2: e260–66. 
8. Matthews T, Danese A, Caspi A, et al. Lonely young adults in modern Britain: findings 
from an epidemiological cohort study. Psychol Med 2019; 49: 268–77. 
9. Sell TK, Boddie C, McGinty EE, et al. Media messages and perception of risk for Ebola 
virus infection, United States. Emerg Infect Dis 2017; 23: 108–11 
10. Wang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of 
health-related misinformation on social media. Soc Sci Med 2019; 240: 112552. 
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Solunke and M: A Case of Mixed Anxiety Depression in the COVID-19 Lockdown
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11. Thompson RR, Garfin DR, Holman EA, Silver RC. Distress, worry, and functioning 
following a global health crisis: a national study of Americans’ responses to Ebola. Clin 
Psychol Sci 2017; 5: 513–21. 
 
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English

A Case of Mixed Anxiety Depression in the COVID-19 Lockdown

Prabhu, Dr. Pranav

Mukthinath, Dr. Gurgi

Digital Journal of Clinical Medicine 
Volume 2 Issue 5 Article 9 
1-1-2020 
A Case of Squamous Cell Carcinoma 
Dr. Pranav Prabhu 
JSS AHER 
Dr. Gurgi Mukthinath 
JSS AHER 
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 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Prabhu, Dr. Pranav and Mukthinath, Dr. Gurgi (2020) "A Case of Squamous Cell Carcinoma," Digital Journal 
of Clinical Medicine: Vol. 2: Iss. 5, Article 9. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
A Case of Squamous Cell Carcinoma 
Dr. Pranav Prabhu,  
Dr. Gurgi Mukthinath ,Associate Professor. General surgery, JSS Medical College, JSS 
AHER, Mysuru  
Clinical History 
The 85-year-old lady presented with complaints of:   Swelling on Right Foot since 2 
months.   The patient was normal 2 months back when she noticed swelling on the Right 
Foot.   
Initially swelling was 1cm x 1cm in size and has gradually progressed to the current size of 
10cm x 8cm and 5cm x 4cm    
Swelling is also associated with bloody discharge, spontaneous, minimal amount of bleeding, 
which stops on its own.   
No h/o trauma No h/o pain on movement 
No h/o skin change No h/o fever No h/o anorexia, weight loss No h/o similar swellings in 
other sites   
Not a k/c/o Type 2 Diabetes Mellitus, Hypertension, Asthma, Epilepsy 
Examination 
General Physical Examination:    
The patient is moderately built and nourished, is alert, cooperative, and well oriented   No 
pallor, No icterus, No clubbing, No cyanosis, Right inguinal lymph node enlarged, No 
edema.   
 
Inspection:  
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Prabhu and Mukthinath: A Case of Squamous Cell Carcinoma
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Two swellings present on the medial aspect of lower 1/3rd of the Right leg   1st swelling of 
size 10cm x 8cm just above the medial malleolus which is exophytic. 
 
The surface appears irregular with ulceration & bloody discharge   Margins are well defined, 
the skin over the swelling is ulcerated with necrotic patches   2nd swelling is 1cm above the 
first swelling, 5cm x 4cm in size, the surface appears irregular, margins are well defined The 
skin over the swelling is stretched and shiny with minimum ulceration 
 
No scars/sinuses   No other swellings are seen   Passive movement at the ankle is normal but 
aggravates bleeding   Insert Picture 1 Palpation: No local rise of temperature Tenderness + 
Solitary swelling, No ridge between the two masses 
Other inspection findings confirmed   Swelling is variable in consistency, non-mobile bleeds 
on touch, the skin over swelling is not pinchable   
 
Examination of draining lymphatics:  
Solitary 1cm x 1cm lymph node, palpable in Right inguinal region Non-tender, freely mobile, 
and firm   CVS: S1 &S2 heard, No added murmurs.   RS: B/L NVBS, No added 
sounds.   P/A: Soft and non-tender with no organomegaly.   CNS: Conscious and oriented. 
 
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Investigations 
Hb – 9.6g/dL 
ECG: Irregular missed beats 
 
 
2D Echocardiography: 
Aortic Valve Sclerosis with Mild Tricuspid Regurgitation with Pulmonary Artery 
Hypertension. 
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Xray of Right Leg: AP, Lateral 
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Serology 
HIV – Negative 
HbsAg – Negative 
HCV – Negative 
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Prabhu and Mukthinath: A Case of Squamous Cell Carcinoma
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Diagnosis  
Squamous Cell Carcinoma over the medial aspect of Right foot 
Treatment 
Wide Local Excision done under Spinal Anaesthesia 
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The tissue sample sent for Histopathological Examination showed high-grade sarcoma 
 
Discussion 
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Prabhu and Mukthinath: A Case of Squamous Cell Carcinoma
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Cutaneous squamous cell carcinoma (cSCC) is a malignant tumor arising from epidermal 
keratinocytes [1] 
It is mainly caused by UV light exposure, which leads to widespread DNA damage and 
extremely high mutational loads [2] 
These cancers can appear as: 
•Rough or scaly red patches, which might bleed 
•Raised growths or lumps 
•Open sores (which may have oozing or crusted areas) that don’t heal or that heal and then 
come back 
•Wart-like growths [3] 
Squamous cell carcinoma (SCC) has a higher risk of metastasis. 
In this case, the patient has inguinal lymph node enlargement indicative of metastasis. 
A skin biopsy is mandatory in all patients with suspected squamous cell carcinoma. 
Histopathologically, squamous cell carcinoma is notable for irregular nests, cords, and sheets 
of neoplastic keratinocytes invading the dermis.  [4] 
Here, in this case, an X-Ray was taken to check the extent of invasion of the tumor, and a 
wide excisional biopsy was done to confirm the diagnosis. 
The major preventive measure includes the use of appropriate sun-protective clothing, the use 
of broad-spectrum (UVA/UVB) sunscreen with at least SPF 50, and avoidance of intense sun 
exposure that may prevent this cancer. [5] 
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Surgical excision is the only means of providing accurate information on histology and 
clearance. A 4 mm clearance margin should be achieved if the SCC measures <2 cm and a 1 
cm clearance margin if >2cm. [6] 
Other procedures include: 
Mohs Surgery (During the surgery, after each removal of tissue and while the patient waits, 
the tissue is examined for cancer cells) [7] 
 Radiation therapy is often used afterward in high-risk cancer or patient types 
In the case of SCC in situ (Bowen’s disease) treatment includes photodynamic therapy with 
5-aminolevulinic acid, cryotherapy, topical 5-fluorouracil or imiquimod, and excision. [8] 
The long-term prognosis of squamous cell carcinomas depends on: the sub-type of the 
carcinoma, available treatments, location(s) and severity, and various patient health-related 
variables (accompanying diseases, age, etc.). Generally, the long-term outcome is positive, as 
less than 4% of Squamous cell carcinoma cases are at risk of metastasis. [9] 
References 
[1] Waldman A, Schmults C. Cutaneous Squamous Cell Carcinoma. Hematol Oncol Clin 
North Am 2019; 33:1   
[2] Robbins Basic Pathology 10th ed. Elsevier 2017. 900P.g   
[3] Christensen SR, Wilson LD, Leffell DJ. Chapter 90: Cancer of the Skin. In: DeVita VT, 
Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and 
Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.   
[4] Kueder-Pajares T, Descalzo MA, García-Doval I, Ríos-Buceta L, Moreno-Ramírez D. 
Evaluation of Structure Indicators for Assessing Skin Cancer Quality of Care in Dermatology 
Departments. Actas Dermosifiliogr. 2018 Nov;109(9):807-812. English, Spanish. doi: 
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10.1016/j.ad.2018.06.004. Epub 2018 Aug 6. PMID: 30093072.. 
  [5] Gallagher, RP; Lee, TK; Bajdik, CD; Borugian, M (2010). “Ultraviolet radiation”. 
Chronic Diseases in Canada. 29 (Suppl 1): 51–68.   
[6] Bailey and Love’s, Short Practice of Surgery 27th ed, Taylor & Francis Group 2018. 
Pg608 
  [7] Steinman HK: Mohs Surgical Techniques In: Gross KG, Steinman HK, Rapini RP. 
Mohs Surgery Fundamentals and Techniques. St Louis: Mosby; 1999. p.49-72.   
[8] Bath-Hextall, Fiona J; Matin, Rubeta N; Wilkinson, David; Leonardi-Bee, Jo (2013-06-
24). “Interventions for cutaneous Bowen’s disease”. Cochrane Database of Systematic 
Reviews (6): CD007281. doi:10.1002/14651858.CD007281.pub2. ISSN 1465-1858. PMC 
6464151. PMID 23794286.   
[9] Brantsch Kay D; Meisner Christoph; Schönfisch Birgitt; Trilling Birgit; Wehner-Caroli 
Jörg; Röcken Martin; Breuninger Helmut (2008). “Analysis of risk factors determining 
prognosis of cutaneous squamous-cell carcinoma: A prospective study”. The Lancet 
Oncology. 9 (8): 713–720. doi:10.1016/S1470-2045(08)70178-5. PMID 18617440.   
 
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A Case of Squamous Cell Carcinoma

S K, Dr. Prabhakar

Digital Journal of Clinical Medicine 
Volume 2 Issue 1 Article 9 
1-1-2020 
Macular and Optic Disc Drusenoid Deposits with Hemifield 
Defects in a patient with IgA Nephropathy: New Findings 
Dr. Prabhakar S K 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
S K, Dr. Prabhakar (2020) "Macular and Optic Disc Drusenoid Deposits with Hemifield Defects in a patient 
with IgA Nephropathy: New Findings," Digital Journal of Clinical Medicine: Vol. 2: Iss. 1, Article 9. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
Macular and Optic Disc Drusenoid Deposits with Hemifield Defects in a patient with 
IgA Nephropathy: New Findings 
Dr. S K Prabhakar, Ophthalmology Department, JSS Hospital  
CLINICAL HISTORY: 
A previously treated 20-year old female patient for skin rashes, hematuria and pain abdomen 
8 months ago, consequently reported with indistinct vision predominantly more in the right 
eye than the left eye for the last one week. 
Previous documents revealed features of leukocytoclastic vasculitis on skin biopsy and 
glomerular mesangial cell hyperplasia on renal biopsy that suggested a clinical diagnosis of 
IgA nephropathy. 
One month after administration of prednisolone 50 mg/day that was tapered over a period of 
8 months, proteinuria manifested 
EXAMINATION AND INVESTIGATIONS: 
General Physical and Systemic Examination: Normal. 
Ophthalmic Examination: 
• Visual acuity recording demonstrated 6/9 and 6/6 in the right and left eye 
respectively. 
• Normal color vision testing. 
• The anterior segment examination was unremarkable. Direct ophthalmoscopy 
• bilateral optic disc hyperemia with indistinct margins, 
• retinal venular engorgement and absent spontaneous venous pulsations with 
irregular and widened normal macular reflex more prominently demonstrated 
in the right eye. 
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S K: Macular and Optic Disc Drusenoid Deposits with Hemifield Defects
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Figure 1 Right eye Fundus camera picture showing distorted normal macular ring reflex with 
irregular reflection at the superior macular area 
 
 
 
 
Figure 2 Left eye Fundus camera picture showing less prominent findings 
 
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Optical coherence tomography (OCT) of the optic disc at the temporal and nasal aspects 
showed hyperechoic intense reflections that probably suggested drusenoid like deposits 
predominantly in the right eye. 
 
 
Figure 3 showing drusenoid deposits in the right eye at the temporal and nasal aspect of the 
optic disc  
 
 
 
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S K: Macular and Optic Disc Drusenoid Deposits with Hemifield Defects
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Figure 4 showing less prominent drusenoid appearance in left eye optic disc 
 
OCT of macula showed a similar echoic configuration in the outer retinal layers and Bruch’s 
membrane that probably suggested drusenoid like deposits with a parafoveal thickening. (Fig 
5 & 6) 
 
Figure 5 Right eye OCT macula showing drusenoid deposits in the outer retinal layers and 
Bruch’s membrane 
 
 
 
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Figure 6 Left eye OCT macula showing less prominent drusenoid deposits 
 
Humphrey field analyzer (HFA) showed inferior hemifield defects more prominently 
observed in her right eye than the left eye. (Fig 7 & 8) 
 
 
Figure 7 showing prominent right inferior visual field defects with blind spot enlargement in 
HFA 
 
 
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S K: Macular and Optic Disc Drusenoid Deposits with Hemifield Defects
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Figure 8 showing less prominent inferior visual field defect with blind-spot enlargement on 
HFA 
 
Hb 10.8 gm/dL 
TLC: 11720 cells/cu mm, 
ESR 60 mm/hour by Wintrobe method. 
Peripheral smear: Normocytic normochromic anemia. 
Urine analysis:  Albuminuria, RBC and pus cells. 
Stool occult blood: Positive. 
RBS, RFT, LFT, serum electrolytes and coagulation profiles were normal. 
C3 and C4 levels: Normal. 
ANA, cANCA, and pANCA: Negative. 
USG abdomen and pelvis: Fatty liver and few mesenteric lymph nodes. 
FINAL DIAGNOSIS: 
IgA nephropathy 
Treatment Given: 
Patient was treated previously with a systemic oral dose of prednisolone 50 mg/day and now 
is on a maintenance dose of 15mg/day 
DISCUSSION: 
IgA nephropathy involves an error in IgA1 glycosylation resulting in IgA1 secretion into the 
systemic circulation. The IgA1 forms complex deposits attached to the extracellular matrix 
and mesangial cells within the glomerulus. This induces mesangial cells to release pro-
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inflammatory mediators and activate the complement system via lectin and alternative 
pathways. (1) 
This young female patient previously diagnosed as IgA nephropathy presented with disturbed 
vision more conspicuously in the right eye similar to the previous reports. (3) Direct 
ophthalmoscope findings correlated with fundus camera photography in addition to OCT 
images. Paramacular hyper reflective echoes observed at the macula was probably due to 
drusenoid deposits similar to the previous case report. OCT of optic disc showed similar 
image characteristic features that were correlated as inferior field defects on HFA, probably is 
the cause for diminished vision in our patient. 
Ocular involvement is very rare in patients with IgA nephropathy. Nevertheless, a previous 
study reported the presence of cotton wool spots, serous retinal detachment, and choroidal 
infarcts on FFA (4) In the present literature, only one case of a 42-year-old patient with IgA 
nephropathy who had small, clustered and well-defined macular deposits reported. (3) 
Rueda-Rueda T et al reported an association of unilateral uveitis in IgA nephropathy. (5) In 
conclusion, we demonstrated new findings of optic disc drusenoid deposits with inferior 
visual field defects in addition to paramacular drusenoid-like deposits in a patient with IgA 
nephropathy. 
 
ACKNOWLEDGEMENTS: None  
 
REFERENCES:  
1. Lally DR, Baumal C. Subretinal Drusenoid Deposits Associated With Complement-
Mediated IgA Nephropathy. JAMA Ophthalmol.2014;132:775–777. 
2. Ehrhardt J, Gelisken F. Acute, bilateral visual loss in a patient with IgA 
glomerulonephritis. Ophthalmologe.2018;115:222-225. [Article in German] 
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S K: Macular and Optic Disc Drusenoid Deposits with Hemifield Defects
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3. Cetin Nuran et al. Perimacular drusenoid deposits in a child with IgA nephropathy. 
Canadian Journal of Ophthalmology.2018;53:71 -74. 
4. Taban M, Chand D, Sears JE. Ocular findings in IgA nephropathy with renal failure 
and hypertension. J Pediatr Ophthalmol Strabismus.2006;43:378-80. 
5. Rueda-Rueda T et al. Unilateral uveitis associated with IgA nephropathy. Arch Soc 
Esp Oftalmol.2017;92:598-601. [Article in English, Spanish] 
 
 
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Macular and Optic Disc Drusenoid Deposits with Hemifield Defects in a patient with IgA Nephropathy: New Findings

Pallavi, Pooja

H.S, Dr. Rajani

Digital Journal of Clinical Medicine 
Volume 2 Issue 3 Article 8 
1-1-2020 
Ataxia Telangiectasia- A Case Report 
Pooja Pallavi 
JSS AHER 
Dr. Rajani H.S 
JSS AHER 
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 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Pallavi, Pooja and H.S, Dr. Rajani (2020) "Ataxia Telangiectasia- A Case Report," Digital Journal of Clinical 
Medicine: Vol. 2: Iss. 3, Article 8. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
Ataxia Telangiectasia- A Case Report 
Pooja Pallavi, Dr. Rajani.H.S , Department of Pediatrics ,JSS Medical College, JSSAHER, 
Mysuru  
 
Clinical History  
18-year-old female, presented with complaints of  reddish discoloration  of both eyes since 12 
years, Involuntary movements of hands since 11 years, Unsteady gait since 8 years, Slurring of 
speech since 8 years, Hair loss since 3 years,  
Now brought with History of Increased frequency of micturition since 1 month 
Past History- 
She had h/o recurrent respiratory and skin infections in first 4 years of life. She 
discontinued school because of physical disability. 
Menstrual History- 
She attained menarche at the age of 14 years 
Birth History- 
Antenatal and perinatal history was normal with normal developmental milestones till 7 years of 
age. 
Family History- 
There were no similar complaints in the family. 
Examination and Investigations 
General: 
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Pallavi and H.S: Ataxia Telangiectasia- A Case Report
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Patient looks grossly wasted and stunted. 
Height– 140cm 
Weight– 34kg 
BMI– 17.3 
Vitals: 
PR: 72bpm 
BP: 110/80 Hg 
RR: 14 breaths /min 
SpO2: 98% 
Head to Toe: 
Head – Thin and sparse hairs with patchy areas of  baldness. 
Eyes– Telangiectasia were seen over  bilateral bulbar conjunctiva (B/L congestion over 
bulbar  conjuctiva) 
Synorphrys  
Hyperpigmentation of skin around eyes 
Acanthosis nigricans over nape of neck 
Café au lait spots 
Cubitus valgus 
Genu valgum 
Deformity on  standing (Knock- Knees) 
Plantar flexion of  B/L feet 
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  Systemic   Examination:   
On CNS examination, 
 The patient was conscious oriented with hypotonia, diminished deep tendon reflexes and 
bilateral plantar flexor.  
Cranial nerve examination was normal except for nystagmus.  
Cerebellar signs  like Wide-based ataxic gait, bilateral nystagmus, scanning speech, intention 
tremor, dysmetria, dysdiadochokinesia  were seen. 
Telangiectasia Genu 
valgum Synophrys Acanthosis nigrans 
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Pallavi and H.S: Ataxia Telangiectasia- A Case Report
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 and sparse hair 
Knocked knees 
Nystagmus 
Unsteady gait and genu valgum 
Scanning Speech 
There were no signs of meningeal irritation 
  Spine was Normal with no kyphoscoliosis 
Other systems  
(CVS,RS, P/A) were unremarkable. 
HbA1c– 12.6 
RBS was 382 mg /dl 
C peptide level was Low with 3.96ng/ml 
MRI Scan 
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 Brain– Mild cerebellar atrophy 
Alpha Fetoprotein was grossly elevated with 166ng/ml 
IgA level was normal with 134 .g/dl 
 IgE level was low with 7.45 IU/ml 
Brain Stem Evoked Response Audiometry (BERA)showed 
Sensorineural  hearing loss on  right side 
Rest of the  tests came out to be normal. 
Molecular  testing and cytogenetic assays could not  be done. 
MRI showing  
  mild cerebellar 
  atrophy 
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BERA Report with Findings
Audiological Evaluation 
Final Diagnosis 
ATAXIA    TELANGIECTASIA 
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Discussion 
Here we have  presented a case  of 18 year old female born to a consanguineous marriage 
with chronic progressive  
ataxia with bilateral telangiectasia,  grossly elevated alpha fetoprotein,  decreased IgA and IgE 
levels and  MRI findings suggestive  of diagnosis of Ataxia Telangiectasia presenting 
with new onset type 2 diabetes mellitus, one of the known association of  A-T [1-3]. 
Ataxia Telangiectasia  also known as “Louis bar syndrome” is a  complex disorder, characterized 
by progressive cerebellar ataxia, neurologic impairment,  immunological abnormalities which 
includes immunoglobulin and antibody deficiencies and lymphopenia, ocular and cutaneous 
telangiectasia, risk of lymphoreticular malignancy, and increased hypersensitivity to ionizing 
radiation [1-3]. 
It is an Autosomal Recessive disorder  With Incidence of  1 in 100,000 live  Births [1] Males and 
females are equally affected [1]. It is caused due to mutation on ATM Gene on 11q22-23 
involved in cell division and DNA  repair [1,3]. 
 Both humoral and cellular immunity are impaired (combined Immunodeficiency) [2,3]  Other 
manifestations include -Recurrent sinopulmonary infections, choreo-athetoid movements 
Premature aging, alopecia areata. Insulin resistant Diabetes, predisposition to development of 
malignancy, Hyper- sensitivity to radiation, slowed growth. 
There is delayed pubertal development, gonadal atrophy/dysgenesis [1-3]. Average life 
expectancy was reported to be approximately 25 years. Two most common cause of death are 
chronic lung disease and cancer [3].   There is no definitive treatment   for A-T. 
  New advances in management includes  gene therapy  and  IVIG  administration [3] 
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Acknowledgements : None 
References 
1. Saleh AA. Ataxia Telangiectasia:a 
case report. Int J Health Sci Res. 2018;8(3):279-281 
2. M Shabeer 
A Nana, N Ali,B pattnaik.JMSCR,2017. June.5(6); 
22915-22917 https://dx.doi.org/10.18535/jmscr/v5i6.19 
3. Rothblum Oviatt 
C., Wright, J.,Lefton-Grief, M.A.et al.Ataxia telangiectasia: a review. 
Orphanet J Rare Dis 11, 159(2016). 
https:/doi.org/10.1186/s13023-016-0543-7 
 
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Ataxia Telangiectasia- A Case Report

Penmetsa, Dr. Pranay

R, Dr. Subramanian

Digital Journal of Clinical Medicine 
Volume 2 Issue 4 Article 8 
1-1-2020 
A Case of Sjogren’s Syndrome with Leucocytoclastic Vasculitis 
with Hypokalemic Periodic Paralysis 
Dr. Pranay Penmetsa 
JSS AHER 
Dr. Subramanian R 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Penmetsa, Dr. Pranay and R, Dr. Subramanian (2020) "A Case of Sjogren’s Syndrome with 
Leucocytoclastic Vasculitis with Hypokalemic Periodic Paralysis," Digital Journal of Clinical Medicine: Vol. 
2: Iss. 4, Article 8. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
A Case of Sjogren’s Syndrome with Leucocytoclastic Vasculitis with Hypokalemic Periodic 
Paralysis 
 
Dr. Pranay Penmetsa, Dr. Subramanian R, Associate Professor And HOD, Dept Of 
Rheumatology & Immunology 
 
CLINICAL HISTORY: 
37-year-old female presented with Complaints of dryness of eyes, mouth for 6 months. 
Tingling sensation in both upper limbs for 3 days, insidious in onset, no postural variation, no 
aggravating and relieving factors 
Complaints of upper and lower limb weakness, insidious onset, progressive, initially able to mix 
food and grip onto slippers now unable to lift hands above the level of head for 2 days, patient 
was able to get up from sitting position initially, now unable to do so.  
Breathlessness since 1-day, insidious onset, progressive, initially on strenuous exercise 
progressed to at  rest (MMRC 0 – MMRC 4), no postural variation, no diurnal variation. History 
of multiple joint pains for 4 days. 
No h/o fever, No mouth ulcers. 
No h/o change in voice, blurring of vision. 
No h/o loss of smell, photophobia, double vision. 
No h/o facial deviation, loss of sensation over face 
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No h/o difficulty in chewing, swallowing 
No h/o auditory disturbances, vertigo, dizziness. 
No h/o deviation of tongue, drooping of shoulder. 
No h/o palpitations, sweating, loss of consciousness 
No h/o increased thirst, increased appetite, increased frequency of passing urine. 
No h/o vomiting, diarrhea, abdominal pain 
She had past h/o Henoch Schoenlein Purpura in 2016 on alternate medication. 10 days post 
discharge, during follow-up for above complaints, she presented with a rash on the lower limbs, 
insidious onset, progressive, erythematous, itchy rash. No other new symptoms.  
EXAMINATION AND INVESTIGATIONS: 
A middle-aged female patient, moderately built and nourished, well oriented to time, place and 
person, alert, conscious and cooperative. 
No Pallor,No Icterus, No Cyanosis, No Clubbing, No Lymphadenopathy, No Edema 
Vitals: 
Pulse rate: 88 bpm 
BP: 100/60 mmHg 
RR: 20 cpm 
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Temperature: Afebrile 
Systemic Examination: 
CVS: S1, S2 heard, no murmurs 
RS: B/L NVBS ++, no added sounds 
PA: Soft, non-tender, no organomegaly 
CNS: 
Higher Mental Functions: Conscious, oriented 
Cranial Nerves: Intact 
Motor System: Bulk Normal, Tone Normal, Power 0/5 in all limbs, Areflexia, Planter reflex was 
mute 
Sensory System: Intact 
Cerebellar Signs: Normal 
Signs of Meningeal Irritation: Absent. 
Local Examination:Multiple maculopapular rash present over both lower limbs, erythematous, 
red to violet color, non-blanching. 
RBS: 136 mg/dl 
LFT: Normal 
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Serology: Negative 
Peripheral Smear: Normocytic, Normochromic with Neutrophilic Leukocytosis. 
Platelet Count: 3.12 Lakh/ cu. mm. 
Electrolytes: 
Sodium: 144 mEq/L    Potassium: 2.9mEq/L 
Chloride: 114 mEq/L 
T3: 0.7 ng/ml 
T4: 6.03 mcg/ml 
TSH: 1.65 mcIU/ml 
PT: 14.2 s 
INR: 1.06 
BT: 2 min 
CT: 5 min 
ABG: 
pH: 7.115 
pCO2: 34.5 
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pO2: 236 
 HCO3: 10.6 
Anion Gap: 5.3 
Na: 139 
K: 2.5 
Cl: 123 
ANA Profile: 
nRNP/Sm: Not Detected 
Sm: Not Detected 
SS-A: Detected (3+) 
Ro 52: Detected (3+) 
SS-B: Detected (2+) 
Scl-70: Not Detected 
PM-Scl: Not Detected 
Jo-1: Not Detected 
CENP: Not Detected 
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Penmetsa and R: A Case of Sjogren’s Syndrome with Leucocytoclastic Vasculitis wit
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PCNA: Not Detected 
dsDNA: Not detected 
Histones: Not Detected 
Rib. P-Protein: Not Detected 
AMA-M2: Not detected 
Urea: 33 mg/dl 
Creatinine: 0.9 mg/dl 
Biopsy of Skin: shows features suggestive of Leucocytoclastic Vasculitis. 
 
FINAL DIAGNOSIS: 
1.Sjogren’s Syndrome 
2.Hypokalemic Periodic Paralysis 
3.Renal Tubular Acidosis 
4.Leucocytoclastic Vasculitis 
 
TREATMENT: 
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Quadriparesis reversed immediately after correction of Hypokalemia which includes infusion of 
KCl.. 2 correction of Inj. KCl was given 1 day apart. 
Syp. POTASSIUM CHLORIDE (POTKLOR) 10 ml 1-1-1 
•Hypokalemia was caused due to Renal Tubular Acidosis which was treated with Sodium 
Bicarbonate and diuretics. Tab. SODIUM BICARBONATE (SODAMINT) 2-2-2 
(ABG report included in investigations) 
Tab. AMITRIPTYLINE( COTRIP) 0-0-1 
Cap.VITAMIN B 12(VICOBA) 1-0-0 
Tab.HYDROXYCHLOROQUINE  (HCQS) 400 mg 0-0-1 
•LCV is treated with oral steroids along with Methotrexate which modulates the immune system 
and reduces the intensity of the disease. 
•Sjögren’s Syndrome was treated symptomatically with eye drops, moisturizing lotion, saliva 
substitutes and immunomodulators like HCQS. 
DISCUSSION: 
Sjögren’s syndrome is divided into primary and secondary forms. The clinical hallmarks of 
Sjögren’s syndrome are keratoconjunctivitis sicca (dry eyes), xerostomia (dry mouth), and 
parotid gland swelling. Extraglandular features of primary Sjögren’s syndrome include fatigue, 
Raynaud’s phenomenon, polyarthralgia/arthritis, interstitial lung disease, neuropathy, and 
purpura. (1)  
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Hypokalaemia Periodic Paralysis (HypoKPP) is a disease that usually occurs at adolescence. 
Men are more often affected because of decreased penetrance in women.  Attacks are often 
provoked by meals high in carbohydrates or sodium and may accompany rest following 
prolonged exercise. 
Weakness usually affects proximal limb muscles more than distal. Ocular and bulbar muscles are 
less likely to be affected. Respiratory muscles are usually spared, but when they are involved, the 
condition may prove fatal. Weakness may take as long as 24 h to resolve. Life-threatening 
cardiac arrhythmias related to hypokalaemia may occur during attacks. A low serum potassium 
level during an attack, excluding secondary causes, establishes the diagnosis. (2)  
Leucocytoclastic Vasculitis is a type of cutaneous vasculitis (Immune Complex mediated 
Vasculitis) which usually presents as a palpable purpura, but a variety of other skin lesions may 
be found including pustules, vesicles, urticaria, and small ulcerations. (1) 
Most cases of idiopathic cutaneous leukocytoclastic vasculitis are mild and resolve with 
supportive measures such as leg elevation, rest, compression stockings, and antihistamines. In 
more chronic or resistant cases, a 4-6 week tapering dose of corticosteroids can be used.  Rarely, 
immunosuppressive steroid-sparing agents such as methotrexate, azathioprine, mycophenolate 
mofetil, dapsone, cyclophosphamide, and intravenous immunoglobulin may be needed. (3) 
ACKNOWLEDGEMENTS: None 
REFERENCES: 
(1)Kelley Textbook of Rheumatology. 
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(2)Harrison’s Principles of Internal Medicine. 
(3) Leukocytoclastic Vasculitis (Hypersensitivity Vasculitis) 
Dana Baigrie; Pankaj Bansal; Amandeep Goyal; Jonathan S. Crane. 
https://www.ncbi.nlm.nih.gov/books/NBK482159/ 
 
 
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Penmetsa and R: A Case of Sjogren’s Syndrome with Leucocytoclastic Vasculitis wit
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A Case of Sjogren’s Syndrome with Leucocytoclastic Vasculitis with Hypokalemic Periodic Paralysis

Khan, Maaz

M, Dr. Bhanukumar

Digital Journal of Clinical Medicine 
Volume 2 Issue 2 Article 8 
1-1-2020 
A CASE OF TETANUS WITH CLASSICAL PRESENTATIONS 
Maaz Khan 
JSS AHER 
Dr. Bhanukumar M 
JSS AHER 
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 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Khan, Maaz and M, Dr. Bhanukumar (2020) "A CASE OF TETANUS WITH CLASSICAL PRESENTATIONS," 
Digital Journal of Clinical Medicine: Vol. 2: Iss. 2, Article 8. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
A CASE OF TETANUS WITH CLASSICAL PRESENTATIONS  
 
Maaz Khan, 7th term MBBS 
Dr. Bhanukumar, Professor, Department of Medicine, JSS Hospital, JSSAHER 
 
Clinical features: 
A 43 year old male arrived to the emergency medical department, with left lower limb spasm since 15 
days, difficulty in opening the jaw since 7 days and back stiffness since 3 days. 
Patient was apparently normal 15 days back, when he suffered a thorn prick on the right foot, 
following which he experienced minor episodes of involuntary muscle spasm in the left lower limb, 
which aggravated on the day on presentation, when he was unable to fold his left lower limb.  
Gives history of  painful contractions of the jaw for 7 days, with difficulty in opening the jaw on the 
day of presentation. 
He experienced diffuse stiffness in the back since 3 days, which has been progressing in nature. 
No history of fever, seizures, or headaches. 
No past history of weakness of limbs. 
No other significant history. 
No history of previous surgeries. 
Examination: 
GENERAL PHYSICAL EXAMINATION: 
A middle aged male patient is cooperative, moderately built and moderately nourished, appears well 
oriented to time, place and person. 
VITALS: 
BP: 140/80mm of Hg 
PR: 90beats/min 
RR: 16 breaths/min 
SpO2: 97% at room air. 
No pallor, icterus, cyanosis, clubbing, oedema or generalized lymphadenopathy. 
RS- B/L Normal vesicular breath sounds  
PER ABDOMEN-soft, non-tender. 
CVS: S1, S2 heard. No murmurs. 
CNS: Conscious, oriented. Increased tone in the left hamstrings and left quadriceps muscles. 
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Khan and M: A CASE OF TETANUS WITH CLASSICAL PRESENTATIONS
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Investigations: 
BLOOD INVESTIGATIONS: 
Hb:14.2gms/dl 
TOTAL WBC: 10210 cells/cu. mm 
DLC: 
N:82.2%, L:13.4%, 
E:0.4%, M:3.8%, B:0.2% 
RBC:4.39 million/ml 
Pcv/Hct: 40.2% 
MCV:91.7fl 
MCH:32.4pg 
MCHC:35.4 gm/dl 
RDW-CV:12.1% 
PLATELET :6.98lakh/ml 
CK-NAC: 1817 U/L 
 
Diagnosis:  
Tetanus 
 
Treatment: 
▪ Debridement and antiseptic cleaning of injury site 
▪ INJ. Tetanus Anti toxin  1000 IU i.m. Stat 
▪ INJ. Diazepam 10 mg i.m. TID 
▪ INJ.Metronidazole 500 mg I.V. every 6 hours 
▪ INJ. Diclofenac 75 i.v. SOS 
▪ INJ.Ceftriaxone 1gm i.v. BID 
▪ INJ. MgSO4 2gm i.v. TID 
▪ INJ.Rabeprazole  20mg i.v. OD 
▪ The patient was placed in a dimly lit isolation room, where he was confined to the bed and 
nourishment was continued via DNS infusions. 
 
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Discussion: 
Tetanus is characterized by acute manifestation of muscle spasms and autonomic system disturbance, 
which is mediated by a neurotoxin produced by the bacterium Clostridium tetani, which is an 
anaerobic, gram positive spore forming rod, whose spores can survive readily in a vast spectrum of 
environments, and is preventable by vaccination. (1) 
Although tetanus is more prevalent in developing countries, cases are still reported throughout the 
world. (2) 
Only the bacteria that produce the ‘Tetanospasmin’ neurotoxin can cause tetanus. The toxin is 
released by the circulating bacterium, and this toxin then in internalized into the surrounding motor 
neurons. The toxin then follows a retrograde pathway through the motor nerves up to the motor 
neuron body, located in the ventral horn of the spine. 
The neurotoxin then travels across synapse to enter the pre-synaptic inhibitory neuron terminals. Here 
the toxin cleaves the Vesical associated Membrane Protein 2 (VAMP2) “Synaptobrevin”, thus 
preventing neurotransmitter release, and effectively blocking inhibitory discharge at the synapse. 
Clinical manifestations of tetanus occur only after the toxin has reached the presynaptic inhibitory 
nerves and very little can be done at that point to control the disease progression.(3) 
The behaviour of generalized tetanus involves initial muscle aches and stiffness that progresses to 
spasm and painful contractures. The first group of muscles to be affect are those of the face and jaw, 
followed by the upper limbs and then progressing towards the lower muscle groups. 
Classical presentation is with trismus (Lockjaw), muscle aches and spasms, backaches and difficulty 
swallowing. If the laryngeal muscle group is involved, it may lead to airway obstruction and hence 
lead to poor prognosis. 
Diagnosis of Tetanus is based on clinical findings after which the treatment should not be delayed, 
while laboratory tests are conducted. A few cases that mimic generalized tetanus, include Strychnine 
poisoning, and dystonic reactions to antidopaminergic drugs. These are differentiated by the fact that 
tetanus has continuous abdominal muscle rigidity, where as the other two conditions have episodic 
abdominal rigidity. 
Treatment primarily involves administration of Human Antitoxin, to deactivate the circulating toxin, 
while antibiotics like metronidazole and penicillin act by purging the bacterium from the body. 
Benzodiazepines like diazepam can also be provided to prevent spasms, and magnesium sulphate is 
used as a muscle relaxant.(4) 
References: 
1. Weinstein L. Tetanus. N Engl J Med. 1973 Dec 13;289(24):1293–6.  
2. AS Fauci, Hauser S, Kasper D, Jameson J, Longo D, Loscalzo J. Harrison’s principles of 
Internal medicine. 20th ed. Vol. 1. New York: Mc Graw Hill; 2020. 1103–1105 p.  
3. Hasan MK, Patwary MI, Fatema K, Alam ST, Tabrez MS, Rahman MM, et al. Demography 
and Symptom Profile of Tetanus: A Cross-sectional Observation in an Infectious Disease 
Hospital of Bangladesh. Mymensingh Med J MMJ. 2020 Jan;29(1):129–35.  
4. Shanbag P, Mauskar A, Masavkar S. Intravenous magnesium sulphate infusion as first-line 
therapy in the control of spasms and muscular rigidity in childhood tetanus. Paediatr Int Child 
Health. 2019;39(3):201–7.  
 
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A CASE OF TETANUS WITH CLASSICAL PRESENTATIONS

T, Dr. Sopan

Digital Journal of Clinical Medicine 
Volume 2 Issue 3 Article 9 
1-1-2020 
A Case of Alcohol Induced Psychotic Disorder with Depression 
presenting during COVID19 lockdown 
Dr. Sopan T 
JSS AHER 
Dr Kishor M 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
T, Dr. Sopan and M, Dr Kishor (2020) "A Case of Alcohol Induced Psychotic Disorder with Depression 
presenting during COVID19 lockdown," Digital Journal of Clinical Medicine: Vol. 2: Iss. 3, Article 9. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
A Case of Alcohol Induced Psychotic Disorder with Depression presenting during 
COVID19 lockdown 
 Dr. Sopan, Dr Kishor M, Department Of Psychiatry ,JSS Medical College, JSS AHER, Mysuru  
 
Clinical History 
A  35 year old male agriculturist residing in rural area, married and has family with two children, 
living in a extended nuclear family presented to the emergency in the night with complaints of 
shaking of hands and body, and hearing voices since 1 day, fatigue since 4 days consumption of 
alcohol since 8 days, sadness for the last 10-12 weeks. 
 
The patient and the spouse reported that he has incurred a loss of approximately Rs 100,000 
(INR) as he was not able to sell his harvest due to the COVID19 lockdown which had increased 
his prior financial burden. The patient already had a loan of Rs 4,00,000 (INR). 
 
The patient reported that he will have to take loan again to buy seeds and materials for the new 
harvest. He reported feeling helpless and worried with loss of interest in various day to day 
activities. 
 
He also reported that he takes alcohol periodically once in 2-3 months but drinks for a few days 
continuously, from morning till night and then remains abstinent for many weeks. 
 
He was abstinent during the entire lockdown but on the day of resumption of alcohol sale on 4th 
May 2020, patient started alcohol and drank in a binge pattern (560 ml -720 ml, from morning 
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T and M: A Case of Alcohol Induced Psychotic Disorder with Depression pres
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till night) neglecting all other activities. He was able to buy alcohol on credit and binge. 
 
The patient reported that he got into a verbal altercation with his relative on a trivial issue which 
made him consume alcohol citing sadness and frustration as the reason. 
 
A day before admission he started to hear many voices of people related to the altercation even 
though there was no one around him. 
 
 The patient had two previous episodes of binge drinking in the past few years which were also 
accompanied by similar depressive episodes. He also had history of one suicide attempt two 
months back during one of his binge drinking episodes. He did not have any history suggestive 
of mania or hypomania. 
 
The patient had a family history of alcohol dependence syndrome in his father and his elder 
brother. The elder brother had committed suicide. 
Examination and Investigations 
General Physical Examination –  
Moderately built and adequately nourished. Withdrawal tremors were present.  
On palpation, the liver was non tender and with no signs of enlargement.   
Mental Status Examination – 
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The patient was poorly kempt and groomed. He was oriented to time, place and person. Rapport 
was established with difficulty during the interview. On the second day. He reported sadness, 
objectively appeared depressed. 
Auditory hallucination “of voices shouting at him” were present. The voices were perceived by 
him to be in the external environment. 
He also expressed ideas of hopelessness and sadness. 
Following investigations were sent: Complete blood picture, Serum Electrolytes and Serum 
Ammonia levels, Liver function tests, Serum Gamma Glutamyl Transferase (GGT) levels and 
HIV, HBsAg, HCV tests. All were within normal range except GGT. 
GGT was raised 760 (Normal 0-60IU/L) indicating recent consumption. 
ASSESSMENTS – 
HAMD– A score of 24 was obtained, indicating severe depression. 
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) was applied to assess for 
the risk of suicide. Results were interpreted as the patient having Suicidal ideation of low 
intensity 
 
Final Diagnosis 
 Mental and behavioral disorders due to use of alcohol: Alcohol (Substance) Induced Psychotic 
disorder 
 
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T and M: A Case of Alcohol Induced Psychotic Disorder with Depression pres
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Discussion 
Out of all the mental health disorders, depression and substance abuse constitute major 
components in the overall burden of disease. In 2017, 197·3 million people had mental disorders 
in India, including 45·7 million (with depressive disorders and 44·9 million with anxiety 
disorders. 
 
The weighted percentage of prevalence of alcohol use disorder was 4.6% according to the 
national mental health survey in 2015-2016. Substance use disorders (SUDs), including alcohol 
use disorder, moderate to severe use of tobacco and use of other drugs (illicit and prescription 
drugs) was prevalent in 22.4 % of the population. 
 
COVID19 crisis in India has significantly impaired all aspects of people’s lives. 
Adding to risk is that people with mood disorders are much more likely to develop substance use 
disorders as presented in this case.Depression in turn has various etiological factors which may 
also include various environmental factors. 
 
In the present case it was due to increased financial burden and occupational 
impairment.Evidence from a recent meta-analysis suggests there is a strong association between 
alcohol use or dependence and development of suicidal ideations, suicide attempts, and 
completed suicide. 
 
This possibility has to be adequately addressed while planning treatment for this patient. 
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Acknowledgements: None 
References 
Murthy R. National mental health survey of India 2015–2016. Indian Journal of Psychiatry. 
2017;59(1):21. 
● Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-Related Risk of Suicidal Ideation, 
Suicide Attempt, and Completed Suicide: A Meta-Analysis. PLOS ONE. 2015;10(5):e0126870. 
●Sagar R, Dandona R, Gururaj G, Dhaliwal R, Singh A, Ferrari A et al. The burden of mental 
disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet 
Psychiatry. 2020;7(2):148-161. 
 
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A Case of Alcohol Induced Psychotic Disorder with Depression presenting during COVID19 lockdown

Digital Journal of Clinical Medicine 
Volume 2 Issue 3 Article 7 
1-1-2020 
Airway Management in case of Granulomatosis with Polyangiitis 
Dr. Pranay Penmetsa 
JSS AHER 
Dr. Subramanian R 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Penmetsa, Dr. Pranay and R, Dr. Subramanian (2020) "Airway Management in case of Granulomatosis with 
Polyangiitis," Digital Journal of Clinical Medicine: Vol. 2: Iss. 3, Article 7. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
Airway Management in case of Granulomatosis with Polyangiitis 
 Dr. Pranay Penmetsa, Dr. Subramanian R, Associate Professor and Head of Department, 
Department Of Rheumatology, And Immunology 
 
Clinical History  
A 33-year-old female, complains of dyspnea for 1 month, insidious in onset, progressive, 
initially MMRC 0 to MMRC 4 (dyspnea on rest), (Modified Medical Research Council 
Grading), no postural variations, no aggravating and relieving factors. 
She also complains of cough with expectoration, insidious onset, progressive, moderate quantity 
sputum, yellow colored sputum, no postural variations, no diurnal variations. 
No h/o fever, ear, nose throat problems. 
No h/o chest pain, palpitations, fatigue, sweating, pedal edema. 
No h/o abdominal pain, vomiting, diarrhea.  
Past History:  
K/c/o AAV (ANCA Associated Vasculitis) for 5 years on regular treatment. 
K/c/o HTN for 5 years on T. LOSARTAN 50mg.  
Not a k/c/o DM, Epilepsy, Asthma, TB, Thyroid derangement 
Examination and Investigations 
Examination: 
GPE:  
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Penmetsa and R: Airway Management in case of Granulomatosis with Polyangiitis
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Middle aged, moderately built and nourished, well oriented to time, place and person, alert, 
conscious and cooperative. 
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema. 
Vitals:  
Pulse Rate: 78 bpm,  
BP: 110/70 mmHg,  
RR:17cpm,  
Temperature: 97 *F 
Systemic Examination: 
CVS: S1, S2 heard, no murmurs. 
RS: B/L A/E+,  
B/L NVBS +  
Right Infrascapular area crepts, 
 rhonchi ++ 
PA: Soft, non-tender, no organomegaly 
CNS: NFND 
Eye: Ciliary Staphyloma ++ in both eyes (Scleral thinning in Left eye from 9 to 5 o clock, 
Corneal thinning from 5-6 o clock, Scleral perforation treated with graft 2 years back),  
Diminished vision in Right eye not improving on pin hole, Pupils round reactive in both eyes. 
Fundus: Normal 
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Investigations: 
TLC: 14300 cells/ cu mm 
PT: 11.8s, 
aPTT: 27.6s, INR:0.79 
cANCA: POSITIVE 
pANCA: Negative 
ANA Profile: Negative 
Laryngoscopic Evaluation: Sub glottic stenosis found with obstruction more than 75% of 
lumen of airway 
Diagnostic Nasal Endoscopy: Deviated nasal septum with nasal spur to left nasal cavity. 
HRCT Thorax:  
Loss of volume in B/L upper lobes with areas of fibrosis. Right apical pleural thickening noted. 
2 nodular lesions in posterior basal segment of Right lower lobe and another nodular lesion in 
left apico-posterior segment. 
Areas of consolidation in superior and posterior basal segments of Right Upper Lobe and medial 
segment of Right Middle lobe. 
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Penmetsa and R: Airway Management in case of Granulomatosis with Polyangiitis
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Irregular thick-walled cavities in right upper lobe, posterior and lateral basal segments of right 
lower lobe and apico-posterior segment in left upper lobe. 
ECG: Normal 
2D ECHO: Normal 
X Ray Neck lateral view 
Sub-glottic stenosis seen in laryngoscopic examination 
 
Final Diagnosis 
Granulomatosis with Polyangiitis and Pulmonary involvement 
Subglottic stenosis 
Systemic Hypertension 
Discussion 
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Key Points: 
Granulomatosis with Polyangiitis (GPA), formerly known as Wegener’s Granulomatosis, is an 
autoimmune disorder that affects small blood vessels. (1) It is included in ANCA Associated 
Vasculitis along with Churg-Strauss Vasculitis and Microscopic Polyangiitis.  
Symptoms include:  
▪ Chronic Sinusitis  
▪ Breathlessness  
▪ Hemoptysis 
▪ Blood in the urine.  
The major autoantigens to which ANCAs are directed within neutrophils and monocytes include 
two enzyme proteins identified in the 1980s as autoantigens, namely, 
▪ Proteinase-3 (PR3) 
▪ Myeloperoxidase (MPO) (2) 
Tracheobronchial Stenosis are serious complications of GPA which can arise at any stage of the 
disease. Timely diagnosis plus optimal treatment and follow-up remain unmet needs. (3)  
T Tube has to be placed in patients of GPA if subglottic stenosis has set in as it can compromise 
airway. It will lead to complete cut off of ventilation and is fatal.  
Ideal treatment is LASER EXCISION but since the patient presented with acute stridor and in 
view of limited resources, tracheostomy with T Tube insertion was done as a life saving 
measure. 
 
Acknowledgements: none 
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Penmetsa and R: Airway Management in case of Granulomatosis with Polyangiitis
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References: 
1) API Textbook of Medicine 
(2) Kelley Textbook of Rheumatology 
(3) Frequency, Treatment, Evolution, and Factors Associated with the Presence of 
Tracheobronchial Stenoses in Granulomatosis with Polyangiitis. 
Retrospective Analysis of a Case Series From a Single Respiratory Referral Center 
Erika Marroquín-Fabián 1 , Natllely Ruiz 1 , Jorge Mena-Zúñiga 1 , Luis Felipe Flores-Suárez 2 
 
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Airway Management in case of Granulomatosis with Polyangiitis

Gangadkar, Dr. Siri

Tandure, Dr. Megha

M, Dr. Kishor

Digital Journal of Clinical Medicine 
Volume 2 Issue 4 Article 6 
1-1-2020 
Multiple Sclerosis with Depression 
Dr. Siri Gangadkar 
JSS AHER 
Dr. Megha Tandure 
JSS AHER 
Dr. Kishor M 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Gangadkar, Dr. Siri; Tandure, Dr. Megha; and M, Dr. Kishor (2020) "Multiple Sclerosis with Depression," 
Digital Journal of Clinical Medicine: Vol. 2: Iss. 4, Article 6. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
 
Multiple Sclerosis with Depression 
 Dr. Siri Gangadkar, Dr. Megha Tandure, Dr. Kishor. M 
 
CLINICAL HISTORY: 
A 34 year old female patient married, resident of Bangalore, educated up to Pre-university, 
homemaker, living in a nuclear family belonging to middle socioeconomic status was referred to 
the psychiatry outpatient department from neurology with complaints of sadness & irritability for 
3 months. 
Patient had a history of Rickettsial fever 5 months back, took treatment  for 15 days & then later 
she presented with  complaints of blurring of vision for 1 month & difficulty in passing urine for 
4 days. Later she was diagnosed with Multiple sclerosis & was on steroid treatment for the last 
12 weeks. Since then patient is experiencing sadness & irritability for trivial issues. 
She also had easy fatigability for the tasks she previously did without being tired like household 
chores. She said she was becoming forgetful. She had disturbed sleep & decreased appetite. 
Patient was worried if she would become better like before and lead her life like before.  
No decrease in interest in previously pleasurable activities.  There are no other co-morbities & 
there was no significant past history of any psychiatric illness or psychiatric illness in the family. 
 
EXAMINATION AND INVESTIGATIONS: 
General physical examination:Patient is moderately built, adequately nourished, conscious, co-
operative, oriented to time, place, person. 
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Systemic examination:Revealed no abnormality except brisk lower limb reflexes with bilateral 
lower limb paucity. 
Blood investigations were within normal limits. 
MRI brain with bilateral orbital cut plain + contrast done showed – non specific hyperintensities 
in left fronto-parieto-temporal deep white matter & left periventricular white matter. 
Visual evoked potential– showed demyelinating neuropathy in the pre-chiasmatic pathway of 
both optic nerve. 
 
MRI BRAIN 
 
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FINAL DIAGNOSIS: 
Organic mood disorder –Moderate Depression with Multiple sclerosis 
WHO ICD10 Criteria:  
1. Depression is characterised by sadness, change in overall activity in a patient with organic 
condition. The only criteria for inclusion of organic mood disorder in this block is their presumed 
direct causation by a cerebral or other physical disorder whose presence has been demonstrated 
independently by means of appropriate physical & laboratory investigation. 
2. The affective disorder must follow the presumed organic disease and be judged not to 
represent an emotional response to the patients knowledge of having symptoms or having the 
symptom of a concurrent brain disorder. 
Differential Diagnosis: Drug induced depression (Steroid Induced) 
 
TREATMENT: 
Patient was started on IV methyl prednisolone & switched over to oral steroids  
Prednisolone 10mg 2-2-0, 
Pantoprazole 40mg 1-0-0 , 
Benfotiamine +Mecobalamin+ Alpha lipoic acid 1-0-0. 
She was started on (SSRI) Escitalopram 10mg OD. Psychological Therapy was initiated  
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DISCUSSION: 
Depression is common in multiple sclerosis. The prevalence of depression in multiple sclerosis 
ranges from 19% to 54% depending on the population sample & diagnostic criteria used. 
Etiologic factors for increasing the prevalence of depression in a demyelinating disease can be 
both biological and psychosocial and female sex, age< 35 years, family history of depression and 
a high level of stress are reported as risk factors1. 
The prevalence of corticosteroid therapy leading to depression is 10%2. In this case it is difficult 
to delineate if depression is related to Multiple Sclerosis or Steroid Induced.  As the patient did 
not have previous psychiatric illness, depression is probably linked to medical condition or the 
treatment given. 
However, since steroid may not be withdrawn in this case, it is important to treat the depression 
as it directly affects the individual in all aspects of life. The possible adverse affects of 
depression on disease course are impaired cognitive functioning, treatment adherence, 
deleterious consequences on quality of life and increased risk of suicide. It may adversely affect 
the Multiple sclerosis and its management. 
ACKNOWLEDGEMENTS: None 
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REFERENCES: 
1. Skokou M, Soubasi E, Gourzis P. Depression in Multiple Sclerosis: A Review of Assessment 
and Treatment Approaches in Adult and Pediatric Populations. ISRN Neurology. 2012;2012:1-6. 
2. Brown E, Chandler P. Mood and Cognitive    Changes During Systemic Corticosteroid 
Therapy. The Primary Care Companion to The Journal of Clinical Psychiatry. 2001;03(01):17-
21. 
3. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders, 
Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. 
 
 
 
 
 
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Multiple Sclerosis with Depression

Rajeev, Dr. Sreelakshmi

Reddy, Dr. Pranahith

K., Ms. Chinmayi

Digital Journal of Clinical Medicine 
Volume 2 Issue 4 Article 7 
1-1-2020 
Suicide Attempt in relation to COVID-19 Crisis 
Dr. Sreelakshmi Rajeev 
JSS AHER 
Dr. Pranahith Reddy 
JSS AHER 
Ms. Chinmayi K. 
JSS AHER 
Dr. Kishor M 
JSS AHER 
Follow this and additional works at: https://rescon.jssuni.edu.in/djcm 
 Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy 
and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons 
Recommended Citation 
Rajeev, Dr. Sreelakshmi; Reddy, Dr. Pranahith; K., Ms. Chinmayi; and M, Dr. Kishor (2020) "Suicide Attempt 
in relation to COVID-19 Crisis," Digital Journal of Clinical Medicine: Vol. 2: Iss. 4, Article 7. 
This Case Report is brought to you for free and open access by Research Connect. It has been accepted for 
inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. 
 
Suicide Attempt in relation to COVID-19 Crisis 
 Dr. Sreelakshmi Rajeev, Dr. Pranahith Reddy, Ms. Chinmayi K. Dr. Kishor M 
 
 
 
CLINICAL HISTORY: 
 
Mrs.S, female, aged 38 years, married with two children , uneducated, a farmer & homemaker, 
hailing from a low socioeconomic nuclear family,  residing from rural area near Mysore, was 
referred by Department of General Medicine with history of attempted suicide by consuming 
multiple tablets. Tablets consumed were -Paracetamol(6), Chlorpheneramine (8), Nimesulide 
100mg+Paracetamol 325mg (6)  on 10th  July 2020,10pm at her residence. 
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With informed consent, the patient was interviewed and she narrated that due to COVID-19 
pandemic, her village with 40 houses, has been arbitrarily separated with fences overnight, even 
on the small roads, which has made commuting difficult. 
Three days before admission when she was walking back home from her field and had to cross a 
fence, she had to move some of the fence. This made other villagers irritated and they scolded 
her for being casual and called for a Panchayat (Local administrative group) meet. 
Her husband was called and was asked to apologize for not following the rules of the village for 
control of COVID19 infection. 
The husband felt humiliated and scolded the patient, which pained her. On the same night she 
locked herself and took all available medications. 
Family members had to break into her room and shifted the patient to tertiary care 
hospital.Intentionality and lethality of act was low and remorse was present.   
Patient denied family history of psychiatric illness or suicide.  
Past psychiatric and medical history: not significant. 
 Pre-morbid personality is well adjusted. No history suggestive of depression or anxiety disorder. 
 
EXAMINATION AND INVESTIGATIONS: 
 
General Physical Examination: 
Moderately built and adequately nourished. General physical and systemic examination was 
unremarkable. 
Mental status examination:  
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The patient was adequately groomed, cooperative and oriented to time, place and person.  
She was preoccupied with thoughts about what happened and feeling guilty. 
The patient expressed concern regarding lack of understanding and open discussion from 
villagers in these times of pandemic.  
Her mood was euthymic and insight was present. 
Assessment: 
Hamilton depression rating scale (HAM-D) :10; Not Significant 
Columbia suicide severity rating scale (C-SSRS): Not significant  
Investigations: 
Liver function test: 
TB:0.34 
DB:0.12 
Total protein:7.2 
Sr Albumin:4.1 
A/G ratio:1.3 
AST:14 
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ALT:9 
ALP:101 
PT:16.2 
INR:1.3 
Ultrasound abdomen: Normal study 
2D echo: Normal study  
ECG: within normal limit 
CBC, RFT, SERUM ELECTROLYTES, RBS, TFT : within normal limits  
HIV, HBsAG, HCV: non-reactive  
FINAL DIAGNOSIS:Impulsive act of Deliberate self- harm 
TREATMENT:  
Pharmacological : 
NS Stomach wash, Intravenous fluids, symptomatic treatment, 
 Injection N-AcetylCysteine 3times a day for two days with regular monitoring of vitals. 
Non-pharmacological: 
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Suicide Prevention contract was taken, patient educated regarding the fear and misconceptions in 
common public regarding the fear of COVID19.  
Supportive psychotherapy offered.  
DISCUSSION:  
The COVID-19 pandemic has led to significantly increased levels of stress at the community, at 
the families and at the individual level. 
Policy measures have been formulated to address and limit the spread of infection. These 
measures may have led heightened vigilance, issue of isolation, limited access to basic 
necessities and financial stress, as well as a rapid dissemination of misinformation have led to 
increased levels of anxiety, fear and psychological stress across the country. [1] 
Social stigma can occur in disease outbreaks, the recent outbreak of COVID19 has caused a lot 
of fear and panic about the disease. Suicides are increasing in India during the ongoing 
pandemic.[2] 
The social distancing that is advocated as a preventative measure to control the spread of 
infection can be misinterpreted and easily manifest as social discrimination.  
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Risk assessment in case of Suicide or Suicide attempt involves looking at past history of suicide 
attempt, family history of suicide, current and past history of psychiatry illness, medical 
comorbidity ( Eg; Thyroid Disorder, Epilepsy etc)  or other recognized risk factors ( Eg; Grief, 
Hopelessness). The index patient did not have any of the risk factors for suicide. This case 
demonstrates how social factors during pandemic such as COVID 19 are beyond conventional 
risk factors for suicide.  
ACKNOWLEDGEMENTS: None 
REFERENCES:  
1. Mental health issues during COVID19 NIMHANS [Internet]. Available from 
https://nimhans.ac.in/wp-content/uploads/2020/04/MentalHealthIssuesCOVID-
19NIMHANS.pdf [Last accessed on 15th July 2020] 
2.Suicide,the epidemic we are overlooking [Internet]. Available from 
https://indianexpress.com/article/opinion/suicide-the-epidemic-we-are -overlooking-6472617/ 
[Last accessed on 15th July 2020] 
3.Thippaiah SM, Nanjappa MS, Math SB. Suicide in India: A preventable epidemic. Indian J 
Med Res 2019;150:324-7 
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