INTRODUCTION:
AIDP following Malaria is a rare clinical presentation. Few cases have been reported so far from India and abroad. It is usually acute onset with rapidly developing areflexic ascending motor paralysis with or without sensory disturbances. Though various mechanisms are postulated it is more likely immunogenic. It responds to I/V immunoglobulin along with anti malarial therapy. Early therapeutic measures lead to good prognosis.

CASE REPORT:
A 16years boy admitted on 18.06.2006 with sudden weakness of all four limbs following 2 days of fever with chill and rigor. Detected to be Falciparum malaria (slide test) and treated locally with chloroquin referred to this hospital.

On admission the patient was febrile, conscious with mild pallor. Other vital signs were normal. Respiratory, CVS and Gastrointestinal system were normal. Neurological examination revealed normal higher intellectual functions without any cranial nerve involvement or pupillary abnormality. Motor examination showed normal bulk and tone of all muscles. Power in both U/L were 3/5 in proximal and 4/5 in distal groups including handgrip weakness. Power in both lower limbs were 2/5 around hip and 3/5 around knee, ankle and feet. There was no abnormal movement. Deep tendon reflexes were absent in all four limbs. Plantar was nonresponsive. All superficial reflexes were absent. Sensory system, autonomic nervous systems were normal without bladder and bowel involvement.

Routine blood examination findings showed Hb- 9gm%, ICT for malaria- PFR ++ and DC, TLC, ESR were normal. Serum electrolytes, urea, creatinine, FBS, and LFT were normal. Chest X-Ray, X-Ray of L.S. Spine and USG of abdomen and pelvis were normal. CSF picture was normal. Nerve conduction study of both median, ulnar and common peroneal nerves revealed gross reduction in amplitude and motor nerve conduction velocity, with prolonged distal latency, and absence of F waves. Sensory was absent in all the nerves.

The patient was treated with full course of injection Artesunate and IV immunoglobulin 24g/day for 5 days. The patient improved after 3 days of completion of immunoglobulin. The patient was discharged in 10th day of admission after fully recovery.

DISCUSSION:
AIDP is seen following viral (herpes virus, CMV, E-B virus etc) bacterial (Campilobacter jejuni, Mycoplasma) or immunization. But it is uncommon following parasitic infection like malaria. It is important to rule out other neurological syndromes that may be unmasked by febrile illness. The pathogenesis of AIDP following malaria is not known. This is possibly to be immunogenic like that occur after viral or bacterial infection. Other possible mechanisms of polyneuropathy may be due to parasitic emboli obstructing vasa nervosum, release of neurotoxins, associated metabolic and nutritional disturbances, immune mediated capillary damage, and release of free radicals and tumor necrosis factors.

AIDP is a variant of GBS encountered rarely following malaria (few case reports after Vivax, Falciparum). Early institution of I/V immunoglobulin results full recovery. Steroid has no role.

AIM: To study level of serum concentration of C-reactive protein (CRP) and lipids in patients of acute ischemic stroke and to ascertain the role of CRP levels and its correlation with lipids.

MATERIALS AND METHODS: The study was done during the period of November 2003 to November 2005. Thirty cases (M-18; F-12) were studied taking into consideration exclusion criteria. Detailed clinical histories including family history, personal history, risk factors, treatment history were taken which included detailed general and systemic examination. Routine investigation like Hb, DC, TLC, ESR, S. Urea, S. Creatinine, FBS, Urine: Routine and Microscopic were done. CT scan of brain was done in all cases. Quantitative estimation of CRP by latex fixation technique was estimated. Lipid profile of all cases was done which included estimation of total serum cholesterol (Enzymatic method), HDL cholesterol (Phosphotungstate method), Serum triglycerides (Colorimetric method), LDL-C & VLDL-C (Indirect method by Friedrich�s equation).

OBSERVATION: Raised CRP and levels of lipids were observed as follows:
Age (in Years) Male Female Total (n=30)
No. of Cases Mean No. of Cases Mean
40-50 5 8.42 2 8.3 8.38
51-60 7 8.3 6 8.4
61-70 4 8.45 3 8.67
71-80 2 8.1 1 8.8
Mean 8.3 Mean 8.5
Raised CRP levels were seen in all cases. In all cases lipids showed normal level except LDL which was slightly raised as suggested by Mean Cholesterol-185mg%, Mean TG �171.31mg%, Mean HDL 47.34mg%,Mean LDL 107.32mg%, Mean VLDL 34.26mg%.

DISCUSSION: Out of 30 patients of CT proven ischemic stroke patients all were with raised CRP (Mean 8.38) but lipid profile was not significantly altered except LDL.

CONCLUSION: CRP level was increased in acute ischemic stroke due to inflammatory process. Lipid levels did not increase as studied by others. So it was concluded that there is no correlation of increased levels of CRP in acute ischemic stroke along with lipids in our study. But raised CRP has got a definite prognostic significance.

AIM & OBJECTIVES:
To study the clinical profile and prognosis of AMI in diabetics in contrast to AMI in non-diabetics in present era of aggressive management of AMI from Janurary2003 to March 2004.

MATERIAL AND METHODS:
In present study 35 patients of AMI with diabetes mellitus and 35 patients of AMI without Diabetes mellitus in Department of General Medicine and Department of Cardiology were included. These patients were assessed & followed up in following manner.

All the patients were subjected for detail clinical examination and history at time of presentation to the hospital with special emphasis on particular complication. Serial ECG was done at Zero hour, 12 hour, 24 hour and daily till date of discharge. Routine X-ray was done in all cases to see evidences of pulmonary hypertension and other pathology. Routine biochemical investigations including liquid profile, blood urea, creatinine, glycosylated Hb, cardiac enzymes was done. Detailed Echo examination was done in all cases. All cases were critically evaluated at the time of discharge and were followed up to 30 days.

OBSERVATION:
The clinical course of acute myocardial infraction (AMI) was compared between 35 known diabetics (Ds) and 35 non-diabetics (NDs). AMI patients matched for age, sex and hospital ward. In both groups similar number of cases with shock pulmonary edema and clinical observed arrhythymias were found. In contrast, diabetic patients had significantly more frequent. A-V and intra-ventricular conduction disorder then non-diabetics (P<0.02). Diabetics also died twice more often from AMI (30%) than matched controls (15%) Diabetics with arrhythymias and/or conduction disorders had a particularly poor prognosis for surviving, the relative risk exceeding 3.

CONCLUSION:

The higher mortality and complication of AMI Diabetics calls for aggressive correction of metabolic and modifiable risk factors, treatment of acute events and secondary prevention,

AIM OF THE STUDY:
Validity of C.S.F. and Serum CRP in the diagnosis of meningitis in adults.

MATERIALS AND METHODS:
Fifty cases of meningitis were taken for study in the Department of Medicine form June 2004 to May 2006. Detailed clinical history, physical examinations and routine laboratory investigations were done including mandatory serum and CSF CRP estimation by semi-quantitative method. Clinical diagnosis of pyogenic (bacterial) and TB meningitis (TBM) was determined by history, physical examination, Routine CBC, CSF cytological and biochemical studies.

OBSERVATION AND DISCUSSION:
Out of 50 cases of meningitis 58% were males, 42% were females. Among the bacterial meningitis group maximum number of cases 8 (53.3%) were adults (26-40 years) and in TBM maximum number of cases 12 (37.5%) are in the age group 26-40 years. Fever and headache were the commonest symptoms in all type of meningitis (100%). Meningeal signs were more marked in bacterial (100%) than in TBM (62.5%) and viral cases. Majority of bacterial meningitis were conscious well oriented (66.6%) or at best confused (20%). Altered level of consciousness was more common among TBM cases (87.5%). CSF cell count in pyogenic meningitis varied from 2000/cmm to 63/cmm and 11(73.3%) cases were predominantly polymorphic whereas 4(26.6%) were dimorphic. Among 32 TBM cases the cell count varied from 150/cmm to 20/cmm . 6(18.7%) were dimorphic and rest 26 (81.25%) were predominantly mononuclear. CSF sugar level was reduced more in bacterial meningitis (<20mg/dl) than in TBM cases whereas it was nearly normal in cases of viral meningitis. The CSF protein levels both in bacterial and TBM are high (> 100 mg/dl) whereas it was nearly normal in viral meningitis. The CSF CRP test was positive in 14 (93.3%) out of 15 bacterial meningitis and 2(6.25%) out of 32 cases of TBM. Serum CRP test was positive in all cases of bacterial and tubercular meningitis (100%).

Type of Meningitis No. of Cases Positive serum CRP Positive CSF - CRP
Bacterial meningitis 15(30%) 15(100%) 14(93.3%)
TB meningitis 32(64%) 32(100%) 2(6.25%)
Viral Meningitis 3(6%) - -
Total 50 47 16

CONCLUSION:

Clinical features, cytological and biochemical study of CSF did not differentiate accurately pyogenic from TBM. It was observed that CSFCRP test was positive in almost all cases of bacterial and partially treated bacterial meningitis. The serum CRP test did not discriminate different meningitis whereas CSF CRP positive indicates pyogenic meningitis with greater validity and CSF CRP negatitivity validates tubercular meningitis

AIM:
1. To study the divalent cation status in essential hypertension and to observe the response to different antihypertensive drugs based on divalent cation status.
2. To emphasize the importance of calcium and magnesium status in essential hypertension to serve as surrogate markers of plasma rennin activity and to initiate antihypertensive drugs accordingly as close as physiological antidote.

MATERIALS AND METHODS:
The present study was conducted among essential hypertensive patients, aged >18years with SBP &#61619; 140 mmHg and DBP &#61619; 90 mmHg after exclusion of severe essential hypertension and secondary hypertensions in the department of Medicine. V.S.S. Medical College & Hospital, Burla from January 2004 to January 2006. There were 50 patients included in the study without any complication or morbidity. Detailed clinical and laboratory examination were performed. Patients with serum ionized calcium values were grouped into three groups i.e., Group 1 with 2.09 &#61617; 0.03, Group 2 with 2.24 &#61617; 0.03 and Group 3 with 2.34 &#61617;0.03 mEq/L of ionized calcium and similarly three groups of patients with serum magnesium values i.e., Group 1 with 2.07 &#61617;0.03 , Group 2 with 1.94 &#61617;0.03 and Group 3 with 1.83&#61617;0.02 mEq/L magnesium according to Laragh et al. These groups represent surrogate of low rennin, normal rennin and high rennin activity status of essential hypertension respectively. Again these patients were divided into two groups i.e, Group A having surrogate of low renin and normal renin activity - surrogate (LREH/NREH) and constituted 40 patients and Group B surrogate of high rennin activity status of essential hypertension (HREH) and constituted 10 patients. Initially Group A patients were treated with Amlodipine and the cross over to Ramipril for 12 weeks with a washout interval of one month between the two treatments. Group B patients were similarly initially treated with Ramipril and the cross over to Amlodipine after a washout period of one month for 12 weeks respectively.

OBSERVATION:
1. By using the divalent cation status as surrogate of rennin activity incidence of low renin, normal renin and high renin essential hypertension was 36%, 44% and 20% respectively.
2. Incidence of low renin essential hypertension (LREH) was 55% in females and high renin essential hypertension (HREH) was 80% in males.
3. Most patients in Group �A (LREH) were in the age group between 56-60 years while in Group �B (HREH) the average age were between 42-45 years.
4. 82.5%(33) cases of Group A responded well to a dose of 5mg of Amoldipine, while 17.5% (7) responded well to 10mg. In comparison with Ramipril 95% (38) cases responded well to 5mg of Ramipril and 5%(2) cases with 2.5 mg of Ramipril.
5. In Group B 90% patients responded to 2.5 mg Ramipril, 10%(1) cases responded to 5 mg Ramipril. In comparison of response to Amlodipine 80% patients required 10 mg dose of Amlodipine.
6. Average SBP, DBP, MAP fall of the end of 12 weeks in Group�A with Amlodipine was 19.8, 13.7 and 15.8 mmHg respectively. While with Ramipril the average falls were 16.45, 7.79 and 10.72 mmHg respectively.
7. The average fall of SBP, DBP, MAP and Ramipril in Group�B were 18, 15.79 and 15.98 mmHg & 14.6, 8.8 and 10.23 mmHg respectively with Amlodipine.

CONCLUSION:
Measurement of serum ionized calcium and serum magnesium levels and according to their level which serve as surrogate marker of plasma renin activity can be classified into low renin, normal renin and high renin status of essential hypertension patients. From the above study, the low renin status patients best responded to calcium channel blocker Amlodipine, while high renin status patients best responded to ACE inhibitor Ramipril. This new innovative approach can help initiate antihypertensive drugs like a physiological antidote in the treatment of essential hypertension and may help to control hypertension and retard or prevent complications in the absence of costly, bothersome and non-availability of plasma renin activity study. SBP- Systolic Blood Pressure, DBP- Diastolic Blood Pressure, MAP- Mean Arterial Pressure, LREH- Low Renin Essential Hypertension, HREH- High Renin Essential Hypertension, NREH- Normal Renin Essential Hypertension.