ASSOCIATION OF PHYSICIANS

OF BANGLADESH

JOURNAL COMMITTEE

ADVISORY BOARD

National Prof. Nurul IslamNational Prof. Brig. (Retd.) Abdul Malik

Prof. M. Amanullah

Prof. M. Nurun Nabi

Maj. Gen. (Rtd.) A. R. Khan

Prof. M.A. Mannan

Prof. A.K.M. Nazimuddowla Chowdhury

Prof. Akhtar Hossain

Prof. R. K. Khondokar

Prof. A. Q. M. B. Chowdhury

Prof. Md. Tahir

Prof. A. F. M. Aminul Islam

Prof. Enayet Ullah

Prof. A. K. Azad Khan

Prof. A. Q. M. Qamaruzzaman

Prof. Hazera Mahtab

Prof. Ferdous Ara J. Janan

Prof. P. Purkayastha

EDITORIAL BOARD

Editor : Prof. Mahmud Hasan

Assistant Editors : Prof. Projesh Kumar Roy

Prof. Khan Abul Kalam Azad

Dr. A.K.M. Mosharraf Hossain

Members : Prof. Fazlul Haque

Prof. Tofayel Ahmed

Prof. Naseem Akhter Chowdhury

Prof. A. K. M. Rafiqueuddin Ahmed

Prof. Anisul Haque

Major Gen. (Retd.) Md. Abdul Moyeed Siddiqui

Prof. Zafar A. Latif

Prof. M.A. Faiz

Prof. Syed Atiqul Haq

Prof. Md. Salimur Rahman

Prof. Chandanendu Bhushan Sarker

Prof. Md. Golam Rabbani

Prof. Md. Abu Siddique

Prof. M. A. Jalil Chowdhury

Prof. Muhammad Rafiqul Alam

Prof. Baren Chakroborty

Dr. Md. Abdur Rahim Miah

ASSOCIATION OF PHYSICIANS

OF BANGLADESH

EXECUTIVE COMMITTEE 2009-2011

President : Professor AKM Rafique Uddin

Vice-Presidents : Professor Syed Atiqul Haq

Professor Md. Abdul Jalil Chowdhury

Secretary General : Dr. AKM Mosharraf Hossain

Joint Secretary : Professor Md. Golam Rabbani

Treasurer : Professor Md. Mujibur Rahman

Secretary for Scientific Affairs : Dr. Abdul Wadud Chowdhury

Organizing Secretary : Professor MA Rashid

Members : Professor Mahmud Hasan

Professor Mobin Khan

Professor AZM Maidul Islam

Professor Md. Abul Kashem Khandaker

Professor Shahana Rahman

Professor Muhammad Rafiqul Alam

Professor Firoz Ahmed Quraishi

Professor Quazi Tariqul Islam

Professor Azizul Kahhar

Ex-officio

Professor Quazi Deen Mohammad

Professor Khwaja Nazimuddin

CONTENTS

Original Articles

Comparative Prevalence of Irritable Bowel Syndrome (IBS) Using Multiple Diagnostic Criteria 1-6

Irin Perveen, Mahmud Hasan

Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated 7-13

Enteric Fever In Bangladesh - A Randomized Trial

Durba Halder, Samir Kumar Kundu, M Matiur Rahman, MA Azhar

Serum Zinc Level in Patients with Vitiligo in a Tertiary Hospital in Bangladesh 14-18

Rubaiya Ali, Nargis Akhtar, Mohammad S. Ahsan, Ayesha Hassan, Mohammad Asifuzzaman

Feeding Practice among Anemic and Non-Anemic Infants and Young Children in 19-24

A Selected Rural Area

Mithun Alamgir, Jannatara Shefa, Khan Shakil Ahmed, Shafinaz Gazi,

Mohammad Ferdous Ur Rahaman, Md. Abul Kalam Azad

Clinico-Epidemiological Profile of Seborrheic Dermatitis 25-28

Lubna Khondker, Md Abdul Wahab, Md Shirajul Islam Khan

Study on Aetiology and Outcome of Fulminant Hepatic Failure in Bangladeshi Patients 29-33

Swadesh Kumar Chakrovortty, Rajib Barua, Dewan Saifuddin Ahmed,

Mohammad Abul Kalam Azad, Abu Bakar Siddique, Md. Abul Kalam Azad

Oral Hygiene Among Type 2 Diabetes Patients: A Study of 276 Cases 34-36

Kulsum Umme, Mahmud A, Azam MG, Ahmed JU, Nazimuddin K

Psychiatric Morbidity among Women Whose Husbands are Living Abroad 37-40

M A Salam, Mohammad S. Ahsan, Nafia F. Chowdhury, Syed F. Shams,

Nahid M. Morshed, Mohsin Ali Shah, Monirul Islam

Review Article

Evidence Based Non Pharmacologic Management of Osteoarthritis: A Review 41-45

Rowsan Ara, Md Zahid Alam, Mohammad Ferdous Ur Rahaman,

Monzoor Quader, Jannatara Shefa

Case Reports

Calf Muscle Myokymia - A Brief Review 46-48

Monzoor Quader, Md Abul Kalam Azad, Md. Abdur Rahim, Syedul Islam,

Akhtarul Islam Chowdhury, Mohammad Ferdous Ur Rahaman

Chest Wall Deformity With Severe Respiratory Distress- A Rare Presentation 49-52

of Parathyroid Adenoma

A K M Motiur Rahman Bhuiyan, Monzoor Quader, Nizam Uddin Ahmed,

Mohammad Abul Kalam Azad, Md Zilan Miah Sarker, Mohammad Mobarock Hossain

Septic Arthritis in a Renal Transplant Patient 53-54

Pradip Kumar Dutta, Sayed Md Jabed, Saibal Das, Md Nurul Huda,

Md Maminul Islam, Dipen Chowdhury,Md Shariful Islam, Abul Kashem, Dipti Chowdhury

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HP, Iranov E, et al. Childhood Leukaemia in Europe

after Chernobyl : 5 years follow-up. Br J Cancer 1996;

73 : 1006-12.

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Bangladesh Journal of Medicine and Professor of

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INSTRUCTION TO AUTHORS

The Journal of Association of Physicians of

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AZITHROMYCIN VERSUS CIPROFLOXACIN FOR THE

TREATMENT OF UNCOMPLICATED ENTERIC FEVER

IN BANGLADESH - A RANDOMIZED TRIAL

DURBA HALDER1, SAMIR KUMAR KUNDU2, M MATIUR RAHMAN3, M A AZHAR4

Abstract

Objectives: The study was carried out in Sir Salimullah Medical College and Mitford Hospital,

Dhaka, in the last one and half year to see the efficacy of azithromycin in treatment of enteric fever

and to compare the clinical efficacy of azithromycin with ciprofloxacin in enteric fever.

Methods: One hundred and twenty eight patients (> 12 years) admitted for a period of January

2006- June 2007, with symptoms and signs of uncomplicated enteric fever were initially enrolled

for study. They were entered into a randomized trial and were treated with either oral azithromycin

(Igm on the 1st day followed by 500 mg for the next 6 days) or oral ciprofloxacin (500 mg twice daily

for 14 days). Blood culture for Salmonella typhi or Salmonella paratyphi were done in all cases.

Total sixty patients were culture positive for either S. typhi or S. paratyphi which were finally

studied. Out of sixty patients fifty three were culture positive for salmonella typhi and seven were

culture positive for Salmonella paratyph. Multiple drug resistance (MDR: resistance to two or more

antibiotics) was found in more than seventy percent patients.

Results: During the study period out of sixty patients, thirty three were receiving azithromycin and

twenty seven were receiving ciprofloxacin. Clinical cure was achieved in thirty (90.90%) patients in

the azithromycin group and in twenty one (77.78%) patients in the ciprofloxacin group. Mean fever

clearance time in the azithromycin group was 4 ± 1.4 days and was 4 ± 1.55 days for ciprofloxacin

group. There was no significant difference of clinical cure between the two treatment groups (p >

0.05). No clinical relapses were detected in any study subject. No major side effects of both drugs

occurred in any study subject.

Conclusion: These results indicated that azithromycin and ciprofloxacin were effective against

enteric fever caused by both sensitive organisms and MDR S. typhi & S. paratyphi. It is concluded

that azithromycin is effective and can be a convenient alternative for the treatment of enteric fever,

especially in developing countries like us where medical resources are scarce.

1. Registrar, Department of Medicine, Sir Salimullah Medical College, Dhaka.

3. Assistant Registrar, NICVD, Dhaka

2. Associate Professor, Department of Medicine, Sir Salimullah Medical College, Dhaka.

3. Professor. Department of Medicine, Sir Salimullah Medical College, Dhaka

Introduction

Enteric fever (typhoid fever) is an acute systemic

illness caused by bacterium Salmonella typhi, S.

paratyphi A, B, sometimes C and occasionally by S.

typhimurium.

The incidence of enteric fever has declined greatly

with the provision of clean water and good sewage

systems in Europe and the USA since the early 20th

century, but the disease remains a serious public-

health problem in developing countries, including

Bangladesh. Poor water supply and sanitation

systems are responsible for its prevalence throughout

the year, either sporadically or epidemically in

Bangladesh1-3.

It remains an underestimated important health

problem in the developing countries4.

Enteric fever is estimated to have caused 21.6 million

illness and 2,16,500 deaths globally in 2000 affecting

all ages5. There is also one case of paratyphoid fever

for every four of typhoid.

For decades chloramphenicol has been highly effective

against S. typhi and S. paratyphi and it often remained

the antibiotic of choice for the treatment of enteric

fever6-7. In late 1980s and 1990s outbreaks of typhoid

caused by organism resistant to chloramphenicol, co-

trimoxazole, ampicillin, and amoxycillin were

reported8.

MDR strains of Salmonella typhi (resistant to two or

more than two antibiotics) have emerged in many

countries, in many areas of Asia and have

necessitated the search for other therapeutic

options9. In 1992, a study in Bangladesh10 showed

Bangladesh J Medicine 2010; 21 : 7-13

Salmonella were sensitive to ciprofloxacin and to

pefloxacin in 100% cases and to ceftriaxone in 97.54%

cases and sensitivity to amoxycillin, co-trimoxazole

and chloramphenicol were about 50% of cases. This

study showed emergence of multidrug-resistant

enteric fever in Bangladesh with changing antibiotic

sensitivity pattern. Since then, ciprofloxacin or third

generation cephalosporins (namely ceftriaxone) have

become the first line of treatment of enteric fever11.

However, isolates of Salmonella typhi and paratyphi-A

with reduced susceptibility to fluoroquinolones and

also resistant to fluoroquinolones have been reported

in Bangladesh, India, Thailand and Vietnam and

Tajikistan 11-13.

In this situation ceftriaxone, cefixime and other 3rd

generation cephalosporins are still highly effective

against S. typhi but high cost and parenteral

administration associated with ceftriaxone, renders

them impractical for some patients. Furthermore, in

a report from Bangladesh shows isolates of S. typhi

with high level of resistance (MIC > 256.0 ug/ml) to

ceftriaxone14. Reports of infection with MDR and

fluoroquinolone resistant Salmonella species have

raised concern that soon no available oral medication

will exist to treat the infection15-16.

Azithromycin, the first drug of azalide class, has in

vitro activity against many enteric intracellular

pathogens, including S. typhi17-19. Previous studies

done in other countries demonstrated that a seven-

day treatment of azithromycin was highly effective

against uncomplicated enteric fever in adults and

children 20-21.

We therefore, want to make a comparative study of

ciprofloxacin and azithromycin in treating

uncomplicated enteric fever. If azithromycin proves

to be effective in treatment of enteric fever, it could

be a promising alternative antibiotic for treatment of

enteric fever. Since azithromycin is an oral drug,

relatively cheaper, can be given to all age group

including pregnant woman, it will be very useful for

our people, particularly, poor rural community.

Materials and Methods

Patients: This study was conducted at the

department of Medicine, Sir Salimullah Medical

College and Mitford Hospital, Dhaka for a period of

one and half years (from January 2006 to June 2007).

Both males and females over 12 years of age admitted

to this hospital with documented fever (oral

temperature > 38.5°c) plus a history of fever for at

least 4 days in addition to two or more of the following

symptoms: abdominal tenderness, hepatomegaly,

splenomegaly, coated tongue with sparing of margins,

toxic physical appearance, relative bradycardia, rose

spots, were eligible for enrollment in the study. Only

patients with blood culture positive for salmonella typhi

or S. paratyphi were finally evaluated. Patient’s

informed consent was obtained before randomization

of the study drug.

Patients were excluded from the study if any of the

following criteria were present: pregnancy or lactation,

allergy to ciprofloxacin or azithromycin, associated

complications of enteric fever like severe

gastrointestinal bleeding, intestinal perforation,

visible jaundice, myocarditis, pneumonia, renal

failure, shock, or coma etc., where oral medication

was not suitable or inability to swallow oral

medication, and treatment within the past 4 days

with an antibiotic.

Methods: After study eligibility was determined and

informed consent was obtained, patients were

randomized to one of the two treatment groups.

Patients were hospitalized during the entire treatment

period and at admission evaluation was made by

history and physical examination in a structured

format. Culture of blood (15 ml) was performed prior

to initiation of antibiotic therapy. After

randomization, subjects were treated in an open label

format with either azithromycin (1 g given orally on

the 1st day followed by 500 mg given orally once daily

for the next six days) or ciprofloxacin (500 mg given

orally twice daily for fourteen days ). Azithromycin

was given one hour before or two hour after eating

food. Blood were obtained for haematologic

measurements like TC of WBC, Hb, ESR, platelet

count, blood film for malarial parasite and biochemical

measurements like S. bilirubin, AST, serum

creatinine and urine was obtained for urine analysis

before subjects receives a study drug. Chest x-ray

and other radiological investigations including

abdominal ultrasound, were performed as clinically

indicated. Subjects were asked regarding changes in

symptomatology and possible adverse events of the

study drugs like nausea, anorexia, vomiting,

diarrhoea, abdominal pain etc. During hospitalization,

vital signs (including body temperature) were

measured at every 8 hours, and thorough clinical

examination based on a structured format was

performed daily. Patients were discharged from the

hospital after they became afebrile for at least two

days. All patients were asked to return to the hospital

after two weeks and four weeks for follow up or early

if they became sick.

For blood culture 5-8 ml specimen of blood was

inoculated into Bactec 6B aerobic bottles (Becton

Dickinson) and incubated in the Bactec incubator

system. Bottles giving a positive signal were

subcultured onto Macconkey and blood agar.

Nonlactose - fermenting colonies were then

biochemically identified and were typed for Salmonella

O antigen by slide agglutination with specific

antisera. Antimicrobial susceptibilities was

determined by disk diffusion. Strains were considered

susceptible when zone diameters for azithromycin

disks containing 15 ug were > 13 mm and those for

ciprofloxacin disks containing 5 ug were > 21 mm.

8

Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever BJM Vol. 21 No. 1

Responses of patients to treatment were classified

by clinical cure, which was defined as the resolution

of all typhoid related symptoms within seven days of

initiating antibiotic therapy. Clinical failure was

defined as the persistence of > 2 typhoid related

symptoms or signs present at study entry or as the

development of a typhoid related complication.

Clinical improvement was defined as partial resolution

of illness.

Clinical relapse was defined as recurrence of fever

and clinical features of typhoid within thirty days of

completing therapy, along with isolation of S. typhi

from the blood.

Defervescence was defined as the first day on which

the maximum temperature was < 38.0°c with

maintenance of the temperature at this level for at

least 48 hours.

Statistical Analysis: The numerical data obtained

from study were analyzed and significance of difference

was estimated by using the statistical methods. Data

were expressed in frequency, percentage, mean, and

standard deviation as applicable. Comparison between

groups were done by standard ‘t’ test, chi-square test

as applicable. Proportions were compared with the

chi-square test with yates’ correction. Normally

distributed data were compared using the student t

test. Variable with a p value of <0.05 were counted as

significant & p value of > 0.05 were counted as

insignificant. All statistics were calculated with SPSS

software version 11.5.

Results and Observations

During the period from January 2006 to June 2007,

one hundred twenty-eight patients (33 male, 23

females) ranging in age from 12 to 45 years (mean, 20

years) were enrolled in the study and randomly

assigned to one of the two treatment groups. A total

of 60 subjects had blood cultures from which S. typhi

or S. paratyphi was isolated, and these subjects

comprised the basis for analysis.

Among 60 (sixty) patients 33 (thirty three) were

receiving azithromycin and 27 (twenty seven) were

receiving ciprofloxacin. 53 (fifty three) patients grew

S. typhi and 7 (seven) patients grew S. paratyphi from

their blood samples. Demographic and pretreatment

laboratory evaluations of the subjects with positive

blood cultures are shown in Table 1.There were no

significant differences between the treatment groups

(Table-I).

In this study, according to culture report Salmonella

typhi was sensitive to azithromycin in 90% cases and

to ciprofloxacin in 78 % cases. Ceftriaxone was

sensitive to 100% cases. Ampicillin/amoxycillin was

sensitive only in 21% of cases, and co-trimoxazole

was only in 27% cases. Nalidixic acid was resistant

to all cases.

Clinical responses were cures or improvements within

5 days of starting treatment in 90.1% of patients

treated with azithromycin and 77.7% of patients

treated with ciprofloxacin (table-2). In both treatment

groups response to treatment were significant, that

means both the trial drugs were effective in treating

enteric fever. Difference in response to both groups

was statistically insignificant (p > 0.05).

Those patients of azithromycin group, who failed to

respond at day 5 after starting treatment, we

continued the same treatment. 1 patient had clinical

improvement on day 7, but other 2 patients showed

no further improvement. So we switched over the

treatment to inj. ceftriaxone (2 gm/day intravenously

for 10 days). No patients in azithromycin group developed

complication. Among the ciprofloxacin group 6 patients

Table-I

Demographic and pretreatment laboratory evaluations of Azithromycin and Ciprofloxacin Groups

Parameter Azithromycin Ciprofloxacin

No of patients 33 27

Age(yrs) Range 16-45 16-45

Mean + SD 20 + 6.38 24 + 3.87

Sex Male 20 13

Female 13 14

Duration of fever before admission(days)

Mean + SD 8.18 + 4.64 6.70 + 4.30

No. of patients with positive blood culture with S. typhi 30 23

No. of patients with positive blood culture with S. paratyphi 3 4

Laboratory values in Mean + SD

Haemoglobin (g/dl) 11.89 + 1.15 11.73 + 1.17

Total count of WBC (×103/cmm) 6.01 + 1.53 5.52 + 1.19

Platelet count (×103/cmm) 231.36 + 33.37 239.88 + 36.49

Aspertate aminotransferase (IU) 46 + 34 41 + 21

Serum creatinine (mg/dl) 0.75 + 0.12 0.73 + 0.13

9

BJM Vol. 21 No. 1 Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever

had no response at day 5 after starting treatment.

For non responders we continued the same treatment

for another 2 days. Subsequently 2 patients became

afebrile on day 7. Two patients in ciprofloxacin group

developed complication. One patient developed

Intestinal perforation and another patient developed

meningitis. For those patients we switched over the

treatment to inj. ceftriaxone (1 to 2 gm/day

intravenously for 10 days).

Patients in both azithromycin and ciprofloxacin

treatment groups who responded to therapy, the mean

times to defervescence was more or less same ( Table-

2). It was 4 ± 1.4 days for azithromycin group and was

4.1 ± 1.55 days for ciprofloxacin group. Though

percentage of response to treatment was 90.1% for

azithromycin group and 77.8% for ciprofloxacin group

was different, but there was no statistically significant

difference in both treatment groups. There was no

statistically significant difference in fever clearance

time in both treatment groups.

Table-III

Comparison of Adverse Effect of Azithromycin and

Ciprofloxacin Groups of Enteric Fever Patients

Adverse Effects Azithromycin Ciprofloxacin

Group (n=33) Group (n=27)

Vomiting and Nausea 6 7

Diarrhoea g 5

Abdominal Pain 5 5

Anorexia 7 9

Some adverse effects (table-3) of both study drugs,

like vomiting, nausea and anorexia, diarrhoea,

abdominal pain, were reported in both treatment

groups. The adverse effects were not severe and did

not result in change of study medication.

A total 47 of 60 (78%) patients returned for follow up

at 2 weeks and 34 of 60 (57%) patients returned for

follow up at 4 weeks. No patients developed clinical

relapse on follow up. Twenty seven patients were

communicated over telephone at six months after

completion of treatment. but none complained of

development of fever within that period. So it has

been presumed that all of them were healthy.

Discussion

Enteric fever is one of the common health problems

of Bangladesh. Reports of infections with

fluoroquinolone resistant Salmonella species have

raised concern that soon no available oral medication

will exist to treat the infection15-16.

Multi-drug resistant enteric fever is now emerging

throughout the world and more common in Indian

subcontinent including Bangladesh 9, 22. Enough

research work has not been done to find out

alternative antimicrobials for treatment of multi-drug

resistant enteric fever in Bangladesh.

The present study was done to see the efficacy of

azithromycin in treating uncomplicated enteric fever

and it’s comparison with ciprofloxacin. Enteric fever

may occur at any age, but the commonest age is

between 10-30 years 23. In this present study the

age of the patients was between 12-45 years.

Maximum number of patients was in the age group of

18 years. This age group of people goes more outside

home and eats frequent outside foods. That may led

to development of enteric fever due lack of proper

hygiene. This result is comparable to other workers1, 24. This study shows overall preponderance of male

over female (1.2: 1). Similar results were also found

in other studies in Bangladesh and India3,25. The

higher number of cases among male is probably due

to the fact that females are brought less frequently

to hospitals because of various social, financial and

religious bars in our male dominated society and also

due to the fact that male goes outside more, takes

outside food more frequently than female.

All the patients in this study came with fever, and,

the duration of fever varied from 3 days to 3 weeks.

Maximum cases presented in the 2nd week. This is

Table-II

Comparison of Clinical Response of Azithromycin and Ciprofloxacin Groups

Variables Azithromycin Group(n = 33) Ciprofloxacin Group(n = 27)

Patients No. Percentage Patients No. Percentage

(%) (%)

Clinical cure on or or before dav 5 30 90.90 21 77.78

No. of days to defervescence after start 4 ±1.4 4±1.55

of treatment (Mean SD >)

X Value =1.095, P>0.50

10

Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever BJM Vol. 21 No. 1

similar to the findings of another study in Bangladesh,

where 13.1% of patients of enteric fever had presented

during the 1st week of illness2. In this study, according

to culture report Salmonella typhi was sensitive to

azithromycin in 90% cases and to ciprofloxacin in 78

% cases. Ceftriaxone was sensitive to 100% cases.

Ampicillin/amoxycillin was sensitive only in 21% of

cases, co-trimoxazole was only in 27% cases. Nalidixic

acid was resistant to all cases. In a study 10 performed

by Alam et al. in Bangladesh 14 years back Salmonella

were sensitive to ciprofloxacin and pefloxacin in 100%

cases and to ceftriaxone in 97.54% cases and

sensitivity to amoxycillin. co-trimoxazole and

chloramphenicol in about 50% of cases. The present

study and the study of Alam et al in 1992 showed the

emergence of multi drug-resistant enteric fever in

Bangladesh with the changing antibiotic sensitivity

pattern. Since 1992, ciprofloxacin or third generation

cephalosporin (namely ceftriaxone) have become the

first line of treatment of enteric fever 8. But in 1999,

ceftriaxone resistant Salmonella typhi was detected

in Bangladesh 14. Ciprofloxacin resistant enteric fever

was found in the western country in 2001 26.

Ciprofloxacin or multi-drug resistant enteric fever

seems to be on increase particularly in the developing

countries including China, India and Pakistan25,27-30.

In this study comparative randomized trial of

azithromycin and ciprofloxacin for treatment of

enteric fever indicates that the two treatments were

effective and comparable. In azithromycin group 90.1%

patients became clinically cured & in ciprofloxacin

group 77% became clinically cured. In this study both

the drugs were effective and comparable and it took

average 5 days for remission of fever. Only few

differences between the two treatment groups were

observed. Though percentage responded to treatment

were different in azithromycin (90.1%) and

ciprofloxacin (77%) group, but they were statistically

insignificant (p>0.05). Fever clearance time in both

treatment groups was also similar. For azithromycin

group it was 4 ±1.4 days and for ciprofloxacin it was

4.1 ±1.55 days. This differences were also statistically

insignificant. Adverse effects of nausea or vomiting,

lightheadedness, dry throat, etc. were reported

occasionally in the both treatment groups. These

events were mild or moderate and did not result in

interruption of therapy and could be attributed in part

to the enteric infections.

Though there is limitation of frequent culture to

confirm relapse, by doing frequent clinical follow up

it was assumed that in both azithromycin and

ciprofloxacin group there was no relapse.

In the present study the two study drugs were very

different in regard to their administration,

pharmacokinetics, and therapeutic principles.

Azithromycin was given once daily in a dose of 1000

mg at 1st day, then 500 mg daily for next 6 days, where

as ciprofloxacin was given 500 mg twice a day for 14

days. Both drugs penetrate cells effectively, and this

intracellular penetration explains the effective

therapeutic activity against the predominantly

intracellular pathogen S. typhi.

In azithromycin group 15% patients showed moderate

sensitivity in culture sensitivity report. Despite

moderate sensitivity in sensitivity reports those

patients got azithromycin and became cured. On the

other hand in spite of 78% disc sensitivity of

ciprofloxacin, 6 patients among ciprofloxacin groups

(out of 27 patients) were not clinically cured.

Ciprofloxacin in spite of disc sensitivity showed poor

clinical response than azithromycin. This indicates

differences of in vitro & in vivo sensitivity in both

treatment groups.

Another interesting finding was that in vitro

resistance to azithromycin did not correlate well with

it’s in vivo effectiveness against enteric fever. This

is possibly because susceptibility testing is based

on serum drug levels, where as for enteric fever, a

major mechanism of action is thought to be

intracellular killing, in which the azithromycin levels

may be 100-fold greater than serum levels 31-33.

Several studies have demonstrated the effectiveness

of azithromycin for the treatment of uncomplicated

enteric fever in children, adolescents, and adults 20-

21, 33. In each of the studies, clinical and

microbiological cure rates have exceeded 90% without

any serious adverse effects or relapses of enteric

fever. The present study also gives the same type

result.

However complete clinical response at discharge and

no relapse on follow up was considered as cure.

During treatment, at the end of treatment and at

follow-up, blood cultures were not done due to

financial constraints. This is the major limitation of

this study.

The result of this comparative randomized trial of

azithromycin and ciprofloxacin for enteric fever

indicated that the two treatments were effective and

comparable by giving clinical cures and improvements.

A 7 day course of azithromycin is effective against

uncomplicated enteric fever in adults. Cost and

compliance, as well as safety and efficacy, need to be

considered when choosing regimens for treating

enteric fever in countries with limited resources

where the disease is endemic. Ciprofloxacin is

cheaper than azithromycin, but due to emergence of

11

BJM Vol. 21 No. 1 Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever

drug resistance, the optimum ciprofloxacin regimen

for these resistant infections will require an increase

in the dose and possibly also the duration of

treatment. This will increase the cost. Patients with

multi drug resistant enteric fever have been treated

successfully with costly drugs like ceftriaxone,

cefixime, aztreonam,6,33-34. On the other hand

azithromycin is much less expensive than the third

generation cephalosporins. The once daily

administration of azithromycin, with the short

duration of therapy, may improve compliance and also

ease treatment of enteric fever. More over

azithromycin will be cost effective and suitable for

use in areas where medical resources are limited.

Conclusion

In this study, azithromycin appears to be as effective

as ciprofloxacin in treating enteric fever. Further study

with repeated culture facilities to prove both

microbiological as well as clinical cure will be very

much helpful for establishing azithromycin in

treatment of enteric fever and testing whether the

duration of therapy can be further shortened to

minimize costs while maintaining efficacy.

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admitted to a diarrhoeal disease hospital in

Bangladesh. Trans Roy Soc Trop Med Hyg 1983;

77: 548-51.

2. Akbar MS, Khan N, Shaha SK. Evaluation of

chloramphenicol and co-trimoxazole in the

treatment of enteric fever. Bangladesh J

ChildHealth1986:10;11-14.

3. Roy Sk, Speelman P, Butler T, Samir N, Thaman H,

stoll BJ. Diarrhoea associated with typhoid fever. J

Infect Dis 1985; 151: 1138-43.

4. Ivanoff B, Levine MM, Lanbert PH. Vaccination

against Typhoid fever ; present status. Bull. Wd

Helh Org 1994; 72: 957-71.

5. Crump JA, Luby SP, Mintz ED. The global burden

of typhoid fever. Bull World Health Organ 2004;

82: 346-53.

6. Acharya G, Butler T, Ho M, Sharma PR, Tiwari M,

Adhikari RK, Khagda JK , Pathak UN. Treatment

of typhoid fever; randomized trial of a three day

course of ceftriaxone versus a fourteen-day course

of chloramphenicol. Am J Trop Med Hyg 1995;

52:162-5.

7. Islam A, Buttler T, Kabir I, Alam NH. Treatment of

enteric fever with ceftriaxone for 5 days or

Chloramphenicol for 14 days: a randomized clinical

trial. Antimicrob Agents Chemother 1993; 37: 1572-

5.

8. Mirja SH, Beeching NJ, Hart CA, Multi-drug

resistant typhoid; a global problem. J Med Microbial

1996; 44: 317-9.

9. White NJ, Parry CM. The treatment of typhoid fever.

Curr Opin Infect Dis 1996; 9: 298-302.

10. Alam MN, Haq SA, Das KK, Mazid MN, Hasan Z,

Ahsan SA,et al. Multi-drug resistant enteric fever

in Bangladesh. Bangladesh Medical Journal 1992;

3:38-41.

11. Asna SM, Haq JA. Decrease of antibiotic resistance

in salmonella typhi isolated from patients attending

hospitals of Dhaka city over a three year period. Int

J Antimicrob Agents 2000; 16:249-51.

12. Nath, G, Tikko A, Manocha H, Tripathi, AK, Gulati

AK. Drug resistance in Salmonella typhi in north

India with special reference to ciprofloxacin J.

Antimicrob. Chemother, 2000; 46: 149-50.

13. Parry C, Wain J, Chinh NT, Vinh Hand, Farrar JJ.

Quinolone-resistant Salmonella typhi in Vietnam.

1998; Lancet; 351: 1289.

14. Saha SK, Talukdar SY, Islam M. and Saha S., A

highly ceftriaxone resistant Salmonella typhi in

Bangladesh. Pediatr. Infect. Dis. J. 1999; 18: 387.

15. Brown JC, Shanahan PM, Jesudason MV, Thomson

CJ, Amyes SG, Mutation responsible for reduced

susceptibility to 4- Fluoroquinolones in clinical

isolates of multi-drug resistant Salmonella typhi In

India. J. Antimicrob Chemother 1996; 37: 891-900.

16. Brown NM, Millar MR, Frost JA, Rowe B,

Ciprofloxaein resistance in Salmonella paratyphi A.

J Antimicrob Chemother 1994; 33: 1258-9.

17. Jones K, felmingham D, ridgway G. In vitro activity

of azithromycin (cp-62, 993), a novel macrolide,

against enteric pathogens. Drugs Exp Clin Res.

1998; 14: 613-5.

18. Metchock B. In vitro activity of azithromycin

compared with other macrolides and oral antibiotics

against salmonella typhi. J. Antimicrob. Chemother

1990; 25: 29-31.

19. Gordillo ME, Singh KV, Murray BE. In vitro activity

of azithromycin against bacterial enteric

pathogens. Antimicrob. Agents Chemother 1993;

37: 1203-5.

20. Tribble D, Girgis N, Habib N, Butler T. Efficacy of

azithromycin for typhoid fever Clin Infect Dis 1995;

21 : 1045-6.

21. Frenck RWJr, Nakhla I, Sultan Y, et al.

Azithromycin versus ceflriaxone for the treatment

of uncomplicated typhoid fever in children. Clin

Infect Dis. 2000; 31: 1134-8.

22. Singh M. The challenge of Multi-drug resistant

Typhoid fever. Indian Paediatrics 1991; 28: 329-

31.

12

Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever BJM Vol. 21 No. 1

23. Park JE. Typhoid fever. In; Textbook of preventive

and social Medicine. 12th ed. India: Banarashi Das

Bhnot Publishers, 1989: 160-1.

24. Hoffman SL. Typhoid fever In; Haunters Tropical

medicine. Stricland TG (editor) 6th edition.

Philadelphia. W. B. Saunders Company. 1984: 282-

97.

25. Gupta SP, Gupta MS, Bhardwaj S, Chugh TD.

Current clinical patterns of typhoid fever: A

prospective study. J Trop Med Hyg 1985; 88: 377-

81.

26. Threlfall EJ, Ward LR. Decreased susceptibility to

ciprofloxacin in Salmonella enterica serotype typhi,

United Kingdom. Emerg. Infect. Dis. 2001; 7: 448-

50.

27. Wang Fu. Treatment of typhoid fever with loxacin.

J. Antimicrobial Chemotherapy 1989; 23: 785-8.

28. Jesudason MV, Malathy B, John TJ. Trend of

increasing levels of minimum inhibitory

concentrations of ciprofloxacin to salmonella typhi.

Indian J Med Res. 1996; 103: 247-9.

29. Hafiz S, Hamedani P. Enoxacin. In vitro efficacy

and its future therapeutic role in the Pakistan health

care system. Clinical Therapeutic; 1989; 11: 232-

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30. Ananda AC, Kataria VK, Singh W, Chatterjee SK.

Epidemic multi-drug resistant enteric fever in

Eastern India (letter). Lancet 1990; 1: 352.

31. Vaudaux BP, Cherpillod J, Dayer P. Concentrations

of azithromycin in tonsilar and /or adenoid tissue

from paediatric patients. J. Antimicrob Chemother

1996; 37: 45-51.

32. Wildfeuer A, Laufen H, Zimmerman T. Distribution

of orally administered azithromycin in various blood

compartments. Int J Clin Pharmacol Ther 1994;

32: 356-60.

33. Wildfeuer A, Laufen H, Zimmermann T. Uptake of

azithromycin by various cells and its intracellular

activity under in vivo conditions. Antimicrob Agents

Chemother 1996; 40: 75-9.

34. Bhutta, ZA, Khan IA, Mollah AM. Therapy of multi-

drug resistant typhoid fever with oral cefixime vs

intravenous ceftriaxone. Pediatr. Infect. Dis. J.

1994; 13: 990-4.

35. Girgis, NI, Sultan Y, Hammad O, Farid Z.

Comparison of the efficacy, safety and cost of

cefixime, ceftriaxone and aztreonam in the treatment

of multidrug resistant Salmonella typhi septicaemia

in children. Paediatr Infect. Dis. J. 1995; 14: 603-

5.

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BJM Vol. 21 No. 1 Azithromycin Versus Ciprofloxacin for the Treatment of Uncomplicated Enteric Fever

Introduction

Myokymia, a form of involuntary muscular movement,

usually can be visualized on the skin as vermicular

or continuous rippling movements.

The word myokymia was used first more than 100

years ago, when Schultze described continuous, slow,

undulating muscular contractions in small muscles

of hands and feet.1Kny used the term myoclonus

fibrillaris multiplex to describe similar clinical

manifestations.2 For the past century, different

authors applied the term myokymia to different

involuntary muscular movements. Most of them

showed electromyographic (EMG) changes.

Case Report

This 13-year-old girl presented to us with pain in

the left calf muscle for 2 months witch was 1st started

while playing badminton. Initially she was treated

with different NSAIDs in adequate dose without any

significant clinical improvement. For the last 15 days

she also noticed that her calf was progressively

increasing in size and became stiff with excessive

sweating on overlying skin. On query she complaint

of discomfort feeling of left calf muscle for last 5

years. On examination her vitals were stable, the

left calf is sweaty, swollen, firm and tender (Fig.-1).

There was frequent rippling movement of the calf

muscles. The other muscles of that limb including

the thigh and leg including knee joint was normal.

Her nervous system examination revealed no

abnormality.

On investigation, CBC was normal. Muscle enzymes

including aminotransferase (SGPT& SGOT),

CALF MUSCLE MYOKYMIA - A BRIEF REVIEWMONZOOR QUADER1, MD ABUL KALAM AZAD2, MD. ABDUR RAHIM3, SYEDUL ISLAM1, AKHTARUL ISLAM

CHOWDHURY1, MOHAMMAD FERDOUS UR RAHAMAN1.

Abstract

Myokymia, a form of involuntary muscular movement, usually can be visualized on the skin as

vermicular or continuous rippling movements in small muscles of hands, limbs, eyes and calf muscles.

Here we present a 13- year-old female who presented with pain and stiffness of left calf muscle for

one month. Her calf muscle was swollen and tender. Muscle enzymes, Electromyography, Nerve

Conduction studies revealed no abnormality. A diagnosis of myokymia of calf muscle was made on

the basis of clinical scenario and exclusion of other relevant diseases and she was on physiotherapy

with partial improvement over a period of 2 months.

Key words: Myokymia

1. Medical Officer, Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka.

2. Associate Professor, Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka.

3. Professor, Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka.

Creatinine kinase and Lactate Dehydrogenase were

normal. S Electrolytes & calcium was also normal.

Thyroid function test was also normal.

USG of the left calf showed oedematous and

thickened both Gastrocnemeus & Soleus. X-ray

chest and X-ray Lumbo-sacral spine was normal. MRI

revealed oedematous and thickened gastrocnemeus

and soleus muscle ( Fig 2a & 2b). Electromyogram

(EMG) & NCV of the left limb was also normal. With

these findings she was diagnosed as myokymia of

the left calf muscle. After counseling the she was

discharged with advice of relevant exercise. On her

follow up after one month, her symptoms partially

subsided.

Fig.-1: Calf hypertrophy on left side

Bangladesh J Medicine 2010; 21 : 46-48

CASE REPORTS

Discussion

Myokymia may present with

• Pain, cramps, spasms, weakness, stiffness, or

twitching of affected muscles.

• Sensory symptoms are reported rarely, unless the

underlying etiology (ies) includes sensory nerve

involvement.

• Typical myokymic discharges also can be seen in

the EMGs of patients referred for totally unrelated

complaints.

Physical

Findings of facial myokymia, segmental or focal

myokymia in other areas of the body, and generalized

myokymia are somewhat different in physical

examination and in their potential etiologies;

therefore, they are discussed separately.

• Facial myokymia

o Affected muscles show slow, undulating, fine

movements on the surface of the skin due to

activation of the most superficial muscle

layers. Facial weakness can be present in the

involved muscles.

o EMG study shows typical myokymic

discharges of spontaneous, rhythmic/

semirhythmic bursts of normal-appearing

potentials of 30-60 Hz. The bursts of each

group of potentials are followed by a period

of silence, with subsequent repetition of

grouped discharges of identical potentials.

The spontaneous activities are not altered

by voluntary activation of the muscles.

• Focal or segmental myokymia

o These types of myokymia commonly are seen

in the limbs or particular segmental level(s).

Physical findings mostly are related to the

underlying etiology(ies), which is usually

asymptomatic and not a major concern of the

patient.

o EMG study shows myokymic discharges

similar to those recorded in facial myokymia.

• Generalized myokymia

o A triad of myokymia, muscular stiffness, and

decreased deep tendon reflexes was first

described by Isaacs in 1961; it also is called

Isaacs syndrome.4

¶ Muscle weakness and atrophy and

excessive sweating are frequently

associated features. Smooth muscles

and cardiac muscles typically are spared.

¶ Sensory symptoms are rarely present.

¶ The muscular stiffness is different than

that seen in myotonia, both clinically and

electrodiagnostically. Although both can

be exacerbated by cold, myokymia can be

detected when the muscle is at rest and

during sleep. Patients with myotonia are

normal at rest; the stiffness is induced

by mechanical stimulation.

o The myotonic discharge recorded by EMG

ceases upon relaxation of the muscle, while

spontaneous grouped discharges of myokymia

persist for some time, well above the

abnormal pattern that was present before the

voluntary contraction.

Fig 2a: Oedematous and thickened gastrocnemeus and

soleus muscle (Coronal segment)

Fig 2b: Oedematous and thickened gastrocnemeus and

soleus muscle ( Cross section)

47

BJM Vol. 21 No. 1 Calf Muscle Myokymia - A Brief Review

¶ The EMG features encountered in

patients with generalized myokymia

include the previously described typical

myokymic discharge or neuromyotonia,

which has a much higher frequency of

discharges (up to 300 Hz).

¶ Generalized myokymia in other clinical

entities shares less consistent clinical

manifestations.

Causes

• Facial myokymia

o This type of myokymia is seen more commonly

than other types.

o Facial myokymia has been reported to be

associated with inflammatory demyelinating

diseases, brainstem neoplasms, Guillain-

Barré syndrome, or other intramedullary

pontine lesions. Facial myokymia also has

been reported in patients with history of

radiotherapy, with findings similar to those

of more common brachial or lumbar radiation

plexopathies.

• Focal or segmental myokymia

o The majority of patients with a history of

radiation therapy have myokymic discharges

detected within the field of radiation.

Metastatic lesions generally are believed to

be less likely to generate myokymia. The

amount of radiation ranges widely, though

myokymia rarely is reported with radiation

doses less than 10 gray (Gy).

o Electrodiagnostic findings are usually

consistent with plexopathy. Other less

common causes include acute or chronic

inflammatory polyradiculoneuropathy5 (with

or without coexistent systemic vasculitis),

ischemic or traumatic focal neuropathy, and

entrapment neuropathy, polyradiculopathy

secondary to torticollis, syringomyelia, and

chronic idiopathic plexopathy.

o Transient myokymia, described in the calf or

hand muscles, was reported after brief

strenuous exercise. It usually resolves

spontaneously over weeks to months

TREATMENT: Most of the cases do not require

treatment. It will get better within weeks to months.

But if the symptom persists or intolerable then we

can add one of the following, Beta blockers,

Carbamazepine, Gabapentine or Baclofen.

Consent

Written informed consent was obtained from the

patient for publication of this case report and

accompanying images. A copy of the written consent

is available for review by the Editor-in-Chief of this

journal.

Competing Interest

The authors declare that they do not have any

competing interests.

References

1. Jorge C, Kattah MD. Superior oblique myokymia.

Curr Neurol Neurosci Rep 2003; 3: 395–400. 

2. Duane A. Unilateral rotary nystagmus. Am Ophthal

Soc 1976; 11: 63–67.

3. Webster R. Recurrent superior oblique myokymia in

a patient with retinitis pigmentosa. Clin Exp Optom

2004; 87(2): 107–109. 

4. Lee JP. Superior oblique myokymia. A possible

etiologic factor. Arch Ophthalmol 1984; 102: 1178–

79. 

5. Hoyt WF, Keane JR. Superior oblique myokymia:

report and discussion on five case of benign

intermittent uniocular microtremor. Arch

Ophthalmol 1970; 84: 461–67. 

6. Brazis PW. The natural history and results of

treatment of superior oblique myokymia. Arch

Ophthalmol 1994; 112: 1063–67. 

7. Leigh JR, Tomsak RL, Seidman SH, Dell ‘Ossolf.

Superior oblique myokymia. Arch Ophthalmol 1991;

109: 1710–13. 

48

BJM Vol. 21 No. 1 Calf Muscle Myokymia - A Brief Review

Introduction

Primary Hyperparathyroidism (PHPT) is an

unstimulated and inappropriately high secretion of

parathyroid hormone for the concentration of plasma

ionized calcium. Primary hyperparathyroidism is

estimated to be prevalent in approximately 1% of adult

population and the usual causes are parathyroid

adenoma, hyperplasia and, rarely, parathyroid

carcinoma. The diagnosis of PHPT is a rarity in

developing countries probably because of the difficulty

of making a diagnosis in an environment where there

are limited facilities for serum calcium estimation,

parathyroid hormone assay and parathyroid gland

imaging. The diagnosis can be very perplexing

especially because the expected hypercalcaemia

associated with PHPT may be masked by calcium,

protein or vitamin D deficiency. It is a case report of

PHPT presenting with severe respiratory distress, due

to chest wall deformity, fever, multiple fractures in

different long and short bones with pneumonia

secondary to parathyroid adenoma.

Case Report

A 26-year-old male hailing from Patuakhali presented

to us with weakness, tingling and numbness of the

limbs for the last 6 years, gradually developing deformity

of chest wall with shortness of breath for 15 months,

decreasing in height for the same duration, unable to

walk for the last 2 months. This young man presented

with weakness of the limbs for the last 6 years. At first

there was proximal muscle weakness, later it became

CHEST WALL DEFORMITY WITH SEVERE

RESPIRATORY DISTRESS- A RARE PRESENTATION OF

PARATHYROID ADENOMA

A K M MOTIUR RAHMAN BHUIYAN1, MONZOOR QUADER2, NIZAM UDDIN AHMED2, MOHAMMAD ABUL

KALAM AZAD2, MD ZILAN MIAH SARKER3, MOHAMMAD MOBAROCK HOSSAIN4

Abstract

Primary hyperparathyroidism is a generalized disorder of calcium, phosphate, and bone metabolism

due to an increased secretion of PTH. The elevation of circulating hormone usually leads to

hypercalcemia and hypophosphatemia. There is great variation in the manifestations. Patients may

present with multiple signs and symptoms, including recurrent nephrolithiasis, peptic ulcers, mental

changes and extensive bone resorption. We present a 26 year old young man of Primary

Hyperthyroidism due to adenoma with severe respiratory distress due to chest wall deformity as a

result of multiple vertebrae and rib fracture. His diagnosis was confirmed by Imaging and FNAC. He

was referred to surgery department but due to poor respiratory and cardiac reserve and also fragile

mandible he was repeatedly refused in preanesthetic check up.

1. Assistant Professor, Department of Medicine, BSMMU.

2. Medical Officer, Department of Medicine, BSMMU.

3. Professor, Department of Medicine, BSMMU.

4. Resident, Department of Cardiology, BSMMU

Fig 1: Severe chest deformity

Bangladesh J Medicine 2010; 21 : 49-52

Investigation shows, Hb: 10.8gm/dl, ESR: 100 mm in

1st hour. Total count 8000/cmm.Thyroid Function test,

TSH 1.92mIU/L, FT4:8.94pmol/L, FT3:2.28pmol/L, S

Creatinine: 0.9mg/dl, S Alkaline Phosphatase: 1703

U/L, Serum corrected Calcium: 15.7mg/dl, S Inorganic

Phosphate: 3.5 mg/dl, S PTH: more than 2500pg/ml,

S Electrolytes and S urea in normal.

X-Ray Skull, hands, pelvis, both knees: Diffuse

Osteopenia with absorption of distal phalanx in both

hands. Bones of the pelvic cavity with thoracic cavity

are deformed. Kyphoscoliosis with reduction of body

height of dorsal vertebrae at different level is seen.

All skeletal survey is competitive with

Hyperparathyroidism.

SG of thyroid: A mixed echogenic area having

internal calcification is noted within the both

parathyroid gland, right one is measuring about 15x13

mm and left one is measuring about 38x22 mm. Both

are suggestive of parathyroid mass. FNAC of

parathyroid mass: Smear show mostly chief cells

and cell with abundant eosinophilic cytoplasm

arranged in clusters and small round nuclei

suggestive of parathyroid adenoma. Spirometry:

Severe restrictive airway disease. Echocardiography:

within normal limit. Parathyroid Scintigraphy:

Suggests suspected case of intrathyroidal parathyroid

adenoma.

Table-I

Laboratory data of patient with their related normal

range

Laboratory variables Patient’s Normal

value Value

S Calcium mg/dl 15.7 8.6-10.8

S Phosphate mg/dl 03.5 2.5-5.0

S Alkaline Phosphatase U/L 1703 100-290

S PTH pg/ml >2500 10-60

Fig.-2: Generalized wasting

generalized. Now he is unable to walk and cannot do

his daily activities. He had multiple low trauma fractures

which healed spontaneously. Now for the last 15

months his height is decreased which is due to multiple

vertebral fracture. He also developed severe shortness

of breath due to chest wall deformity. He had

kyphoscoliosis with fracture of multiple ribs and clavicle.

Other systemic examination including cardiovascular,

respiratory and abdomen revealed no abnormality.

Fig.-3: CXR: Suggestive of old healed pulmonary

inflammatory lesion, old healed fracture of multiple ribs

with chest deformity

Fig.-4: X-ray right knee and elbow joint: severe bone

resorption with fracture

50

Chest Wall Deformity with Severe Respiratory Distress BJM Vol. 21 No. 1

After the investigations we have diagnosed him as a

case of primary hyperparathyroidism. We have treated

him with optimum medical management by

consultation with endocrinologist and latter referred

him to endocrine surgery wing of surgery department

of BSMMU. Who agreed for the surgical removal of

the adenoma. But due to poor respiratory and cardiac

reserve and also fragile mandible and chest he was

repeatedly refused in the preanaesthetic checkup.

So he was discharged with adequate medical

management and return after improvement of general

condition for anaesthesia fitness and adenoma

removal.

Discussion

Primary hyperparathyroidism (PHPT) is a disease

commonly due to solitary parathyroid adenoma. It

was considered rare in developing countries but

recent experience has shown that its apparent rarity

may be due to paucity of reports from these countries

and also to limited diagnostic facilities. Our case

has shown that with adequate facilities, more reports

of the disease may soon be emanating from

developing countries. Primary hyperparathyroidism

(PHPT) has protean manifestations. The advent of

automated serum biochemical analysis has highly

augmented its diagnosis. The incidence of metabolic

bone disease in patients with PHPT in developing

countries is very high. The reasons for this are the

high prevalence of protein, vitamin D and dietary

calcium deficiencies and the high dietary phytate

and phosphates in some cultures. It is therefore

pertinent for clinicians practicing in the developing

countries to note that nutritional deficiencies can

be seen in their patients, unlike those from the

developed nations, making hypercalcaemia irrelevant

in the diagnosis of PHPT.

Severe respiratory distress with chest wall deformity

although uncommon, they suggest a late presentation

of the disease and the severity of the disease.

Parathyroidectomy is the treatment of choice in

PHPT. Success of the surgery is determined largely

by early diagnosis and localization of the adenoma

before surgery.

Parathyroidectomy is indicated in patients who meet

some of the following criteria:1. Age <50 years; 2.

Serum Calcium concentrations>1mg/dl above the

upper limit of normal;3. 24 hr urinary calcium

>400mg;4. Creatinine clearance reduced by 30%; 5.

Reduced bone mineral density(BMD; T score<-2.5) at

any site. Open parathyroidectomy is the treatment

of choice in PHPT.

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10. Pattou F, Huglo D, Proye C, “Radionuclide scanning

in parathyroid diseases,” British J Surgery 1998;. 85

(12): 1605–1616.

Fig.-5: Parathyroid scintigraphy showing Adenoma

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BJM Vol. 21 No. 1 Chest Wall Deformity with Severe Respiratory Distress

11. Alvarado R, Meyer-Rochow G, Sywak M, Delbridge

L, Sidhu S, “Bilateral internal jugular venous

sampling for parathyroid hormone determination in

patients with nonlocalizing primary

hyperparathyroidism,” World J Surg 2010; 1 34: (6):

1299–1303.

12 Patel C N, Salahudeen H M, Lansdown M,

Scarsbrook A F, “Clinical utility of ultrasound and

Tc sestamibi 4 Case Reports in Medicine SPECT/

CT for preoperative localization of parathyroid

adenoma in patients with primary

hyperparathyroidism,” Clin Radiol 2010; 65 (4), 278–

287.

13. Su A W, Chen C F, Huang C K. Chen PCH, Chen

WM, Chen TH, “Primary hyperparathyroidism with

brown tumor mimicking metastatic bone

malignancy,” J Chinese Medical Association 2010;

73(3): 177–180.

14. Res´endiz-Colosia J A, Alvarado-Cabrero I, Flores-

D´ýaz R et al., “Multiple maxillofacial brown tumors

as primary hyperparathyroidism manifestation,”

Gaceta Medica de Mexico 2008; 144 (2) 155–160.

15. Lanitis S, Sivakumar S, Zaman N, Westerland O,

Al Mufti R, Hadjiminas D J, “Recurrent acute

pancreatitis as the first and sole presentation of

undiagnosed primary hyperparathyroidism,” Ann

Royal Coll Surg England 2010; 92 (2): W29–W31.

16. Siddiqui F, Weissman DE. “Hypercalcemia of

malignancy #151.” J Palliative Med 2010; 13 (1); 77–

78.

17. Berger AD, Wu WB, Eisner H, Cooperberg MR, Duh

QY, Stoller ML. “Patients With Primary

Hyperparathyroidism—why do some form stones?”

J Urology 2009; 181 (5): 2141–2145.

18 Suh JM, Cronan JJ, Monchik JM. “Primary

hyperparathyroidism: is there an increased

prevalence of renal stone disease?” Am J Roentgen

2008; 191 (3); 908–911.

19. Vander Walde LH, Liu ILA, Haigh PI. “Effect of bone

mineral density and parathyroidectomy on fracture

risk in primary hyperparathyroidism,” World J Surg

2009; 33 (3): 406–411.

20. VanderWalde LH, Liu IL, O’Connell TX, Haigh PI.

“The effect of parathyroidectomy on bone fracture

risk in patients with primary hyperparathyroidism,”

Archives of Surg 2006; 141(9): 885–89.

21. Wu B, Haigh PI, Hwang R et al. “Underutilization of

parathyroidectomy in elderly patients with

primaryhyperparathyroidism,” J Clin Endocrinol

Metabolism 2010; 95(9), 4324–30.

52

Chest Wall Deformity with Severe Respiratory Distress BJM Vol. 21 No. 1

Introduction

Seborrheic dermatitis, also known as seborrheic

eczema, is a chronic papulo-squamous dermatosis

that is associated with increased sebum production

(seborrhea) of the scalp and the sebaceous follicle -

rich areas of the face and trunk.1 Seborrheic dermatitis

is a common disease and occurring in 2% to 5% of the

population. Dandruff, the mildest form of seborrheic

dermatitis, is probably far more common and is present

in an estimated 15-20% of the population. Seborrheic

dermatitis is more common in patients with

Parkinson’s disease or mood disorders and those with

HIV/ AIDS than in the general population. The

prevalence of seborrheic dermatitis among HIV-positive

and AIDS patients between 34% and 83%. The disease

is characterized by scaling on an erythematous base.

Itching may be severe. In extreme cases a greasy, dirty

crust with an offensive odor covers the entire scalp.

The lesions may also become generalized and progress

to a generalized exfoliative erythroderma (erythroderma

desquamativum).2 The cause of seborrheic dermatitis

CLINICO-EPIDEMIOLOGICAL PROFILE OF

SEBORRHEIC DERMATITIS

LUBNA KHONDKER1, MD ABDUL WAHAB2, MD SHIRAJUL ISLAM KHAN3

Abstract

A cross sectional study was carried out with total one hundred thirty seven patients of seborrheic

dermatitis for a period of total two years from department of Dermatology and Venereology,

Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, Bangladesh to assess the clinico-

epidemiological profile of seborrheic dermatitis. The mean age of the patients was 36±6.6 years and

among the patients, highest percentage of patients, 88(64.2%) were in between the 31-40 years

old, 71(51.8%) had higher secondary level of education, 79(57.7%) had monthly family income

>10,000 taka, 124(90.5%) were married, 79(57.7%) were male and 58(42.30%) were involve in

business. It was observed that 88(64.2%) had complaints of itching, followed by 79(57.7%) had

complaints of greasy crust and 58(42.3%) had complaints of seborrhea. It was seen that maximum

48(35.0%) had been suffering for less than 1 year of duration and 88(64.2%) had involvement of

scalp, followed by eyebrow 37(27%) and other areas. It was observed that erythema was mild in

58(42.3%) cases; moderate in 31(22.6%) cases, severe in 27(19.7%) cases and 21(15.3%) had no

erythema. It was showed that 77(56.2) % had mild type papular eruption, 16(11.7) had moderate

and 7(5.1) had severe papular eruption and 37(27.0) had no papular eruption and it was observed

that squamation was mild in 74(54.0) cases, moderate in 43(31.4) cases, and severe in 20(14.0)

cases. It was showed that 58(42.3%) had no associated disease but 37(27.0) had pityriasis versicolor,

20(14.0) had acne vulgaris, 16(11.7%) had neurological disorder and some other disease associated

with seborrheic dermatitis.

Key words: Seborrheic dermatitis, clinical profile, epidemiological profile.

1. Specialist in Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University (BSMMU),

Shahbag, Dhaka, Bangladesh.

2. Associate Professor, Department of Dermatology and Venereology, BSMMU

3. Specialist in Dermatology and Venereology, Combined Military hospital (CMH), Dhaka cantonment, Dhaka,

Bangladesh.

is unknown; Immunological, nutritional,

environmental and lifestyle factors that might increase

the predisposition to seborrheic dermatitis. There may

also be a hormonal influence, not only those the

disease begin to develop at puberty, but seborrheic

dermatitis is more common in men than in women,

suggesting an influence of androgens on the

pilosebaceous unit. Seborrheic dermatitis is also

associated with chronic alcoholic pancreatitis,

hepatitis C virus and various cancers.3. Arsenic, gold,

methyldopa, cimetidine, and narcoleptics drugs; post

encephalitic parkinsonism, epilepsy, poliomyelitis,

syringomyelia, biotin deficiency and abnormal

metabolism of essential fatty acids have been proposed

as possible mechanisms. 1 Seborrheic dermatitis may

be coincident with other dermatological disorders, e.g.

rosacea, ocular irritation or blepharitis. Diseases

associated with Malassezia spp. are also commonly

found in patients with seborrheic dermatitis, these

include pityriasis versicolor and pityrosporum

folliculitis. Seborrheic dermatitis in HIV-positive and

Bangladesh J Medicine 2010; 21 : 25-28

AIDS patients is more severe than the usual immune

deficiencies.4 Patients with seborrhoeic dermatitis may

show up regulation of interferon (IFN)-g, expressed

interleukin (IL)-6, expressed-IL-1a, and IL-4.

Expressions of cytotoxicity activating ligands and

recruitment of natural killer (NK) cells have also been

noted.2 Unfortunately there is no data base study with

the profile of disease over Bangladeshi people. Limited

information is available regarding this. The present

study was designed to assess the profile of seborrheic

dermatitis.

Materials and Methods

This was a cross sectional study, carried out for a

period of total two years from January 2008 to December

2009. Total one hundred thirty seven patients of

seborrheic dermatitis were subjected purposively from

department of Dermatology and Venereology,

Bangabandhu Sheikh Mujib Medical University

(BSMMU), Dhaka, Bangladesh. Purposive type non-

probability sampling technique was followed in this

study. Questionnaire was developed for collection of

relevant information. By face to face interview and also

from clinical record data were collected from patient.

The patient of seborrheic dermatitis was identified first

and verbal and written consent was taken from

patients. Then clinical conditions of the patient were

recorded by us. After collection of data, all the data

were analyzed by software SPSS (Statistical Package

for Social Science) method.

Results

Total one hundred thirty seven patients were studied

for a period of total two years. The mean age of the

patients in table-I was 36±6.6 years and their highest

percentage of patients, 88(64.2%) were in between

the 31-40 years old, followed by 20(14%) were 21 to

30 years old, 16(11.7%) were 41-50 years old, 7(5.1%)

were 51-60 years old and 6(16.2%) were in between

the 11-20 years old. It was found that 15(10.9%) had

primary level of education, 27(19.7%) had secondary

level of education, 71(51.8%) had higher secondary

level of education, 21(15.3%) had graduation level of

education and 3(2.2%) were illiterate. Among the

patients, more than half the patients 79(57.7%) had

monthly family income >10,000 taka and 37(27%) had

monthly family income 6000 to10, 000 taka and

21(15.3%) had monthly family income 1000 to 5000

taka. The mean monthly family income was 10,432.43

taka with standard deviation of 4,186.88 taka and it

was observed that 124(90.5%) were married and only

13(9.5%) were unmarried. It was found from figure I

that majority of patients 79(57.7%) were male and

58(42.3%) were female. Figure II showed that majority

of the patients 58(42.30%) were involve in business

and 21(15.30%) were house wife, 27(19.70%) were

service holder, 20(14%) were student and 11(8%) were

engaged in other types of occupation. The table II

observed that 88(64.2%) had complaints of itching,

followed by 79(57.7%) had complaints of greasy crust

and 58(42.3%) had complaints of seborrhea. Among

the 137 patients, 48(35.0%) had been suffering for

less than 1 years of duration, 31(22.6%) had been

suffering for 1 to 5 years of duration, 37(27%) had

been suffering from 6 to 10 years and 21(15.3%)

patient had been sufferings for more than 10 years.

Regarding site of the lesion, maximum 88(64.2%) had

involvement of scalp, followed by face 37(27%), trunk

21(15.3%), creases (naso-labial, submammary, axilla,

groin and gluteal creases) 20(14%), ear 16(11.7%), and

involvement of other area were 15(10.9%). Table III

showed that erythema was mild in 58(42.3%) cases,

moderate in 31(22.6%) cases, severe in 27(19.7%)

cases and 21(15.3) had no erythema. It was observed

that 77(56.2%) had mild type papular eruption,

16(11.75) had moderate and 7(5.1%) had severe

papular eruption and 37(27.0%) had no papular

eruption. Regarding grading of squamation of the

patients, it was observed that squamation was mild

in 74(54.0%) cases, moderate in 43(31.4%) cases, and

severe in 20(14.0%) cases. Table IV showed the

distribution of patients by associated diseases and

it was observed that 58(42.3%) had no associated

disease but 37(27.0) had pityriasis versicolor, 20(14.0)

had acne vulgaris, 16(11.7%) had neurological disorder,

3(2.2%) had rosacea, 2(1.4%) had psychiatric disorder

and 1(0.7%) had HIV infection.

Table I

Distribution of the patient by epidemiological profile

(n=137)

Epidemiological profile Frequency

Age(in years)

11-20 6(4.4%)

21-30 20(14.0)

31-40 88(64.2)

41-50 16(11.7)

51-60 7(5.1)

Level of educational

Primary level 15(10.9)

Secondary level 27(19.7)

Higher Secondary level 71(51.8)

Graduate and above 21(15.3)

Illiterate 3(2.2)

Monthly income

1000-5000 21(15.3)

6000-10000 37(27.0)

>10000 79(57.7)

Marital status

Married 124(90.5%)

Unmarried 13(9.5%)

26

Clinico-Epidemiological Profile of Seborrheic Dermatitis BJM Vol. 21 No. 1

Table II

Distribution of the patient by complaints, duration of

lesions and site of lesions (n=137).

Parameters Frequency

Complaints

Itching 88(64.2%)

Greasy crust 79(57.7%)

Seborrhoea 58(42.3%)

Duration of lesion

Less than 1 year 48(35.0%)

1 to 5 years 31(22.6%)

6 to 10 years 37(27.0%)

More than 10 years 21(15.3%)

Site of lesion

Scalp 88(64.2%)

Face (eyebrow, eyelid etc) 37(27%)

Trunk 21(15.3%)

Creases area 20(14%)

Ear 16(11.7%)

Others 15(10.9%)

Table III

Distribution of patients by clinical findings (n=137).

Clinical findings Frequency

Erythema

Normal 21(15.3%)

Mild 58(42.3%)

Moderate 31(22.6%)

Severe 27(19.7%)

Papular eruption

Normal 37(27.0%)

Mild 77(56.2%)

Moderate 16(11.7%)

Severe 7(5.1%)

Squamation

Normal 0(00%)

Mild 74(54.0%)

Moderate 43(31.4%)

Severe 20(14.0%)

Table IV

Distribution of patients of seborrheic dermatitis by

associated diseases (n=137)

Associated diseases Frequency

No 58(42.3%)

Pityriasis versicolor 37(27.0)

Acne vulgaris 20(14.0)

Neurological disorder 16(11.7%)

Rosacea 3(2.2%)

Psychiatric disorder 2(1.4%)

HIV infection 1(0.7%)

Discussion

Total one hundred thirty seven patients were enrolled.

The mean age of the patients was 36±6.6 years and

their highest percentage of patients, 88(64.2%) were

in between the 31-40 years old, followed by 20(14%)

were 21 to 30 years old, 16(11.7%) were 41-50 years

old, 7(5.1%) were 51-60 years old and 6(16.2%) were

in between the 11-20 years old, similar to the study

finding of Baysal et al where thirty two adult patients

with seborrheic dermatitis were recruited for the study

with mean age 33.31±9.03 years and age ranged from

18-57 years.6 It was found that majority of patients

79(57.7%) were male and 58(42.3%) were female,

similar to the study finding of Baysal et al where

Fig.-I: Distribution of the patient by sex.

Fig.-2: Distribution of the patient by occupation.

27

BJM Vol. 21 No. 1 Clinico-Epidemiological Profile of Seborrheic Dermatitis

among thirty two adult patients 19(59.4%) were male

and 13(40.6%) were female and also similar to the

study finding of Koca et al where among eighty four

adult patients 52(61.9%) were male and 32(38.1%)

were female.6,7

It was observed that 88(64.2%) had complaints of

itching, followed by 79(57.7%) had complaints of greasy

crust and 58(42.3%) had complaints of seborrhea and

regarding site of the lesion, maximum 88(64.2%) had

involvement of scalp, followed by face 37(27%) and

trunk 21(15.3%), similar finding observed by Freedberg

and James.1,2 Table III showed that erythema was

mild in 58(42.3%) cases, moderate in 31(22.6%) cases,

severe in 27(19.7%) cases and 21(15.3) had no

erythema. It was observed that 77(56.2%) had mild

type papular eruption, 16(11.75) had moderate and

7(5.1%) had severe papular eruption and 37(27.0%)

had no papular eruption. Regarding grading of

squamation of the patients, it was observed that

squamation was mild in 74(54.0%) cases, moderate

in 43(31.4%) cases, and severe in 20(14.0%) cases,

similar finding observed by Freedberg.1 It was

observed that 58(42.3%) had no associated disease

but 37(27.0) had pityriasis versicolor, 20(14.0) had

acne vulgaris, 16(11.7%) had neurological disorder,

3(2.2%) had rosacea, 2(1.4%) had psychiatric disorder

and 1(0.7%) had HIV infection, similar finding observed

by Gupta et al, where seborrheic dermatitis were

associated with rosacea and acne vulgaris.8

Conclusion

The study revealed that majority of patients of

seborrheic dermatitis were within the thirty one to

forty years old, higher secondary level of education,

monthly family income more than ten thousand taka,

married, male and engaged in business mainly. Among

the patients, most patients had itching and greasy

crust than seborrhea, duration of lesion mainly less

than one year, involve mainly scalp and then face

and trunk. It was observed that majority of patients

had mild type erythema, papular eruption and

squamation and associated with pityriasis versicolor

and acne vulgaris mainly.

References:

1. Freedberg IM, Eisen AZ, Wolff K, Austen KF,

Goldsmith LA and Katz SI. Fitzpatrick’s Dermatology

in General Medicine. 6th edition. The McGraw- Hill

Companies; 2003:1198-1204.

2. James WD, Berger TG and Elston D. Andrews’

Diseases of the skin- Clinical Dermatology. 10th

edition. Saunders Elsevier; 2006:191-192.

3. Gupta AK, Bluhm R. Seborrheic dermatitis. J

European Academy Dermatol Venereol 2004; 18: 13-

26.

4. Dunic I, Vesic S, Jevtovic DJ. Oral candidiasis and

seborrheic dermatitis in HIV infected patients on

highly active antiretroviral therapy. HIV Med. 2004

Jan; 5(1): 50-54.

5. Kose O, Erbil H, Gur AR. Oral itraconazole for the

treatment of Seborrheic dermatitis: an open,

non-comparative trial. J Europ Academy Dermatol

Venereol (JEADV) 2008; 19(2): 172-175.

6. Baysal V, Yildirim M, Ozcanli C and Ceyhan M.

Itraconazole for the treatment of Seborrheic

dermatitis: a new treatment modality. Intern Society

Dermatol Int J Dermatol 2004; 43:63-66.

7. Koca R, Altinyazar HC, Esturk E. Is topical

metronidazole effective in seborrheic dermatitis?

Adouble blind study. Int J Dermatol. 2003 Aug; 42(8):

632-5

8. Gupta AK, Bluhm R, Cooper EA, Summerbell RC,

Batra R. Seborrheic dermatitis. Dermatol Clin. 2003

Jul; 21(3): 401-412.

9. Hay RJ, Graham-Brown RA.” Dandruff and

seborrhoeic dermatitis: causes and management “.

Clin Experiment Dermatol 1997 ; 22 (1): 3–6

10. Janniger CK, Schwartz RA. “Seborrheic dermatitis”.

Am Family Physician 1995; 52 (1): 149–55, 159–

60.

11. Nowicki R. “Modern management of dandruff “(in

Polish). Polski Merkuriusz Lekarski 2006 Jan; 20

(115): 121–4.

12. Parry ME, Sharpe GR. “Seborrhoeic dermatitis is

not caused by an altered immune response to

Malassezia yeast”. British J Dermatol 1998 Aug; 139

(2): 254–63.

13. Schwartz RA, Janusz CA, Janniger CK. “Seborrheic

dermatitis: an overview”. Am Family Physician

2006 July ; 74 (1): 125–30.

14. Schwartz JR, Rocchetta H, Asawanonda P, Luo F,

Thomas JH. Does tachyphylaxis occur in long-

term management of scalp seborrheic dermatitis with

pyrithione zinc-based treatments? Int J

Dermatol 2009; 48(1):79-85.

15. Wolverton SE. Comprehensive Dermatologic Drug

Therapy. W. B. Saunders Company; 2001: 62-66.

16. Johnson BA and Nunley JR. Treatment of Seborrheic

dermatitis. Am Academy Family Physicians 2000;

61:2703-10.

17. Elish D, Silverberg NB. Infantile seborrheic

dermatitis. Cutis 2006; 77(5):297- 300.

18. Bergbrant IM. Seborrhoeic dermatitis and

Pityrosporum ovale: cultural, immunologic and

clinical studies. Acta Derm Venereol 1991; Suppl.

167: 10-36.

28

Clinico-Epidemiological Profile of Seborrheic Dermatitis BJM Vol. 21 No. 1

Introduction

Functional gastrointestinal disorders and in

particular irritable bowel syndrome is a common

disorder and has a world wide distribution. The over

all prevalence rate is similar (approximately 10-20%)

in most industrialized countries1, 2, 3. A few studies

conducted in Bangladesh reported that IBS is a

common disorder in this population4, 5, 6. However

their sample sizes were small and included selected

groups of subjects. In the first community based

survey using Rome II criteria, authors reported a

prevalence of IBS of 24.4% in a rural population4.

It has been suggested that the variation in the

prevalence of IBS may be due to the application of

different diagnostic criteria. The prevalence estimates

for IBS from population survey among American,

European and Australian adults vary from 2.1-32%

due to the diversity of definitional criteria used7, 8, 9,

10, 11. The prevalence estimates varies even in the

COMPARATIVE PREVALENCE OF IRRITABLE BOWEL

SYNDROME (IBS) USING MULTIPLE DIAGNOSTIC

CRITERIA

IRIN PERVEEN1, MAHMUD HASAN2

Abstract

Object : The variation in the prevalence of IBS may be due to the application of different diagnostic

criteria. This study aimed to find out the comparative prevalence of IBS in an urban community

using different standard definitions (Rome and Manning criteria) and to determine the degree of

agreement between these definitions.

Methods: This population-based cross-sectional survey involved interview of 1503 persons (15 -

97years) in an urban community using a valid questionnaire based on internationally accepted

Manning and Rome criteria. The threshold for a positive diagnosis varied from two to three Manning

criteria, Rome I and Rome II criteria. Statistical analysis was performed with Statistical package for

social science (SPSS) programmers and the level of significance was set at P d” 0.05. A Kappa (K)

statistics were calculated to assess the agreement between the study definitions.

Results : A response rate of 97.2% yielded 1503 questionnaires for analysis. Prevalence estimates

of IBS according to Manning > 2, Manning > 3, Rome-I and Rome-II criteria were 7.3, 1.8%, 7.7% and

8.1% respectively. IBS was 1.3 to 1.7 times more prevalent in females than males irrespective of the

diagnostic criteria used. A ‘substantial’ to ‘near perfect’ agreement between all commonly used

definitions of IBS with highest level of agreement between Rome-I and Rome-II (k of 0.912) were

found in the present study.

Conclusion: The prevalence of IBS varies significantly depending of the diagnostic criteria employed.

It can be assumed that nearly all the standard definitions (Manning >2, Rome I and Rome II) are

almost equally sensitive in identifying IBS subjects in the community.

1. Consultant, Gastroenterology, BIHS Hospital, Darus Salam, Dhaka, Bangladesh.

2. Former Chairman and Professor, Department of Gastroenterology, BSMMU

same population when different diagnostic criteria

are used simultaneously9,12, 13, 14. In general, studies

requiring only two Manning criteria gave a higher

prevalence estimates than those requiring more

stringent criteria, such as 3 Manning or Rome criteria.

Although Masud et. al.4 used Rome II and Manning

criteria in the rural survey, no comparative study was

conducted in Bangladesh using multiple criteria in

the same population.

The aim of the present study was to find out the

overall prevalence of IBS in an urban community of

Bangladesh using different standard definitions

(Rome and Manning criteria). This study also aimed

to assess how the use of different diagnostic criteria

influences estimated IBS prevalence.

Materials and Methods

This observational study was conducted from the

months of November 2004 to March 2005. A valid

Bangladesh J Medicine 2010; 21 : 1-6

ORIGINAL ARTICLES

questionnaire was administered, using home-based

personal interviews, to 1503 subjects aged > 15 years

in a defined area of Dhaka city of Bangladesh.

Questionnaire: The questionnaire was based on

previously published study12 conducted abroad and

internationally accepted Manning and Rome criteria

for diagnosis. Bengali translation of the questionnaire

was validated by the method of forward and backward

translation. For quality assurance, and to evaluate

the comprehensibility and appropriateness of the

information, an initial survey with the questionnaire

was done on 30 selected samples. That initial survey

showed that the questions were easily

understandable by the study population.

Study definitions:

For the study, 4 main definitions of IBS were

considered: “Manning ³ 2”, “Manning ³ 3”, “Rome-1”,

and “Rome-II”. “Manning ³ 2” required the presence

of recurrent abdominal pain (more than six times in

the past one year) and two or more of the six

“Manning” criteria occurring at least 25% of time in

the past one year. “Manning 3” required recurrent

abdominal pain and three or more Manning criteria

(appendix-1).

“Rome –I” criteria required recurrent abdominal pain

(more than six times in the past one year) and at

least one of the three abdominal pain symptoms as

out lined in appendix-1 occurring more than a quarter

of the time in the past one year, plus two or more of

the five Rome defaecation symptoms occurring more

than 25% of the time in the preceding one year.

“Rome-II” criteria required abdominal pain and at

least two or more of the three abdominal pain

symptoms (appendix-1) occurring more than a quarter

of the time in the preceding one-year.

Appendix I

Diagnostic Criteria for Irritable Bowel Syndrome.

Manning Criteria Rome I Criteria Revised Rome Criteria

( Rome II)

Two or more of the following At least 3 months of continuous *At least 12 weeks, which need not be

symptoms: or recurrent symptoms of consecutive, in the preceding 12 months

of abdominal discomfort or pain that has

2of 3 features:

*Abdominal pain relieved by *Abdominal pain or discomfort –

defaecation. 1.Relieved with defaecation; and/or 1.Relieved with defaecation; and/or

*Looser stools with 2. Associated with a change in 2.Onset associated with a change in

onset of pain. frequency of stool; and/or frequency of stool; and/or

*More frequent stools with 3. Associated with a change in 3. Onset associated with a change in

the pain onset. consistency of stool: and/or form (appearance) of stool.

*Passage of mucous with *Two or more of the following, at least *Symptoms that cumulatively support

stools on one-fourth of occasions or days: the diagnosis of IBS:

*Abdominal distension 1. Altered stool frequency (for 1. Abnormal stool frequency

(visible). research purpose “altered” may be (for research purposes, “abnormal”

*Sensation of incomplete defined as >3 bowel movements each may be defined as greater than 3

rectal evacuation. day or <3 bowel movements each week); bowel movements per day and less

than 3 bowel movements per week);

2. Altered stool form (hard /lumpy 2. Abnormal stool form (lumpy /

or loose/watery ) ; hard or loose/watery stool);

3. Abnormal stool passage (straining, 3. Altered stool passage (straining,

urgency ,or feeling of incomplete urgency, feeling of incomplete

evacuation); evacuation);

4. Passage of mucous; andUsually 4. Passage of mucous;

with :

*Bloating or feeling of abdominal 5. Bloating or feeling of abdominal

distension. distension.

2

Comparative Prevalence of IBS Using Multiple Diagnostic Criteria BJM Vol. 21 No. 1

No laboratory tests or endoscopic examinations were

done in the study due to lack of feasibility.

Statistical analysis: The statistical analysis was

performed with computer-based Statistical package

for social science (SPSS) programmers. Age and sex

specific prevalence of IBS was found out by each of

the three criteria. Six comparisons were made between

the criteria i.e. each of the two Rome definitions were

compared separately to the Manning definitions and

comparisons were also made between Manning

definitions and Rome definitions. Kappa (k) values,

along with 95% confidence interval, were calculated

for each comparison. Significance value during

comparisons were assessed using Chi-squared test

with Yates’ correction, whenever necessary, and the

level of significance was set at P d” 0.05 .

Results

The area included in this study had 1547 persons

aged 15 years and above. Of them, 744 were male and

793 were female, out of which 726 males (97.58%)

and 777 females (97.98%) were interviewed and

included in this study. The mean age of the study

population was 32.18 ±12.98 years with an age range

of 15 to 97 years.

Prevalence of IBS

The sociodemographic characters and the crude, age

and gender specific, prevalence estimates of IBS

subjects are described in table-I. The overall,

unadjusted estimates ranged from 1.8 (Manning >3)

to 7.3 (Manning >2) cases per 100 using Manning

definitions, and from 7.7 to 8.8 cases per 100 using

the Rome study definitions. When more liberal

Table-I

Sociodemographic characteristics, prevalence, and individual symptom of IBS segregated by different study definitions

Variable Manning > 2 Rome-I Rome- II

Mean age ,years 33.65 + 13.24 33.87 + 13.24 33.59 + 13.6

Gender; n (prevalence) Male 41(6.5%) {P< .016} 53 (7.3%) {P< 0.05} 49 (6.7%) (P–ns }

Female 69(8.9%) 79(10.2%) 67 (8.6%)

Total 110(7.3%) 132(8.8%) 116(7.7%)

Age; prevalence (n)

15-24 years 6.31(43) 7.46(39) 6.9(36)

25-34 years 7.14(26) 9.07(33) 8.0(29)

35-44 years 8.9(27) {P-ns} 9.51(29 {P-ns} 8.2(25) {P-ns}

45-54 years 7.17(16) 9.41(21) 7.2(16)

55-64 years 7.7(5) 10.8(7) 10.8(7)

> 65 13.04(3) 13.04(3) 13.04(3)

Pain with more bowel movement, n,(%) 110 (100%) 132 (100%) 116(100%)

Pain with less bowel movement, n, (%) 7(6.36%) 11(.3%) 11(9.5%)

Pain associated with loose stools, n, (%) 78 (70.9%) 86(65.2%) 86(74.1%)

Pain associated with hard stools, n, (%) 20 (18.2%) 29(22.0%) 30(26.1%)

>3 bowel motions per day , n, (%) 26 (23.6%) 34(25.8%) 29(25%)

< 3 bowel motions/ week, n, (%) 4 (3.6%) 6(4.5%) 6(5.2%)

Loose stools, n, (%) 56 (50.9%) 70(53.0%) 67(57.8%)

Hard stools, n, (%) 19 (17.2%) 28(21.2%) 23(19.8%)

Straining, n, (%) 10(9.1%) 15(11.4%) 14(12.06%)

Urgency, n, (%) 4 (3.6%) 7(5.3%) 6(5.2%)

Incomplete Evacuation, n, (%) 25(22.7%) 29(22.1%) 25(21.5%)

Pain decreasing with bowel movements, n, (%) 32(29%) 51(38.6%) 43(37%)

Mucous, n, (%) 9(8.2%) 16(12.2%) 15(13%)

Bloating/ distension, n, (%) 59(53.6%) 65(49.2%) 54(46.5%)

ns- Not significant

3

BJM Vol. 21 No. 1 Comparative Prevalence of IBS Using Multiple Diagnostic Criteria

criteria were used, such as Manning >2 without pain,

prevalence estimate rose to 27.9% and when more

strict criteria were used, such as pain with Manning

>3, prevalence estimate dropped to 1.8%. The gender-

specific prevalence ranged from 2.6 (Manning >3) to

10.2 cases per 100 in women (Rome-I), and from 1

(Manning >3) to 7.3(Rome-I) cases per 100 in men.

IBS was 1.3-1.7 times more prevalent in females than

in males irrespective of the diagnostic criteria used

(P-0.016 in Manning >2, 0.019 in Rome-I). No other

sociodemographic variable (occupation, financial

status) was found to affect IBS prevalence estimates

irrespective of the diagnostic criteria used.

Overlap of IBS Diagnostic Categories:

There was considerable overlap applying the different

diagnostic definitions. For example, 132 subjects met

criteria for Rome I and, of them, 114 also met the

Rome II criteria (k-0.91). On the other hand, 12(10.9%)

of the subjects who met the Manning criteria did not

meet Rome-II criteria. Table- 2 shows the

concordance / agreement between the different

diagnostic criteria. Highest level of agreement was

found between Rome-I and Rome-II comparison by

k-value of 0.912(95% confidence interval: 0.875-0.949).

Lowest agreement was seen in the Manning >3 versus

Manning >2 comparisons by k value of 0.301(95% CI:

0.201-0.401) in this study.

Table- II

Degree of agreement between the Manning and Rome

criteria

a) Manning > 2 vs. Rome-I

Rome-I

IBS No IBS Total

Manning >2

IBS 109 1 110

No IBS 23 1370 1393

Total 132 1371 1503

Kappa (95% CI) = 0.89( 0.85-0.93}; P< .022

b) Manning > 2 vs. Rome-II

Rome-II

IBS No IBS Total

Manning>2 2

IBS 98 12 110

No IBS 18 1375 1393

Total 116 1387 1503

Kappa(95% CI) = 0.856(0.805-0.907); P< 0.000

c) Rome-I vs. Rome-II

Rome-II

IBS No IBS Total

Rome-I

IBS 114 18 132

No IBS 2 1369 1371

Total 116 1387 1503

Kappa (95%CI) = 0.912(0.875-0.949); P<0.

d) Manning > 2 vs. Manning > 3

Manning > 3

IBS No IBS Total

Manning > 2

IBS 22 88 110

No IBS 5 1388 1393

Total 27 1476 1503

Kappa (95%CI) = 0.301(0.201-0.401); P<0.0

e) Rome-I vs. Manning > 3

Manning > 3

IBS No IBS Total

Rome-I

IBS 27 105 132

No IBS 0 1371 1371

Total 116 1476 1503

Kappa (95%CI) = 0.319(0.227-0.411); P<0.000.

f) Manning > vs. Rome II

Rome-II

IBS No IBS Total

Manning >3

IBS 27 0 27

No IBS 89 1387 1476

Total 116 387 1503

Kappa (95%CI) = 0.59(0.259-0.459); P<0.000.

Discussion

This is the first study to obtain comparative

prevalence on IBS using multiple diagnostic criteria

in an urban population of Bangladesh. In the present

study an IBS prevalence of 1.8%, 7.3%, 8.8% and 7.7%

were found using Manning > 3, Manning > 2, Rome I

4

Comparative Prevalence of IBS Using Multiple Diagnostic Criteria BJM Vol. 21 No. 1

and Rome II criteria respectively. The prevalence of

IBS varied from 16.5-24.4% in three surveys conducted

in Bangladesh4, 5, 6. The studies by Rahman et al6

and Raihan et al5 were not population based. Although

the authors reported a prevalence of 30.5% and 24.4%

using Manning criteria and Rome II criteria

respectively in the only rural community-based

survey4; Manning criteria did not required the

persistence of symptoms (> 25% of the time) in their

study. The prevalence was 8.5% when strict Rome II

criteria were used. This is similar to Rome II study

definition of the present survey. Studies from other

developing countries reported IBS prevalence of 4.4-

30.2% using Manning criteria7, 15, 16, 17. But none of

these were population-based and only a few were in

the urban area involving selected subjects. When more

stringent criteria were used in this study, such as

Rome-I or Rome-II, prevalence estimates were 7.7-

8.8 %, which is comparable to other studies3, 12, 18,

19 conducted in western urban areas. A lower

prevalence of IBS (7.3%) was found in the present

study in comparison to that of other urban studies

conducted in western countries (13.6-22%)8, 12, 20

using two or more Manning criteria. But Boice et.

al.12 did not used the pain criteria where as others

did not required the persistence of symptoms (i.e.

>25% of times)8, 20. In this survey data were collected

by personal interview with a high response rate and

accuracy rate. Besides all the persons in the locality

were included in the survey, so the data of present

study likely to reflect the true prevalence of IBS.

A greater preponderance of IBS symptoms in women

compared to men in the present study (1.3 to 1.7times)

supports the previous findings of female

preponderance of IBS in Bangladesh4, 5, 6 and also in

western countries9, 20, 21. Like in other studies4, 6, 14

a downward trend of IBS prevalence with increasing

age was also noted in the present data.

Due to lack of feasibility, no investigation was done

on the IBS subjects. Studies showed that in the

absence of alarm symptoms diagnostic criteria have

a positive predictive value of approximately 98% and

that additional diagnostic tests have a yield of 2% or

less22.

Overlapping of IBS study definitions

The diagnostic thresholds of IBS vary on two

dimensions: duration and severity. Although the

original publication by Manning did not require the

duration criteria, in the present study Manning

definitions required symptoms to be chronic or

recurrent for at least 12 weeks which may or may not

be consecutive in the past one year. The present study

demonstrated good agreement between all commonly

used definitions of IBS according to Kappa values

(table-2). Highest level of agreement was found

between Rome-I and Rome-II: for which a k of

0.912(95% confidence interval: 0.875-0.949) was

calculated. This finding is consistent with that of

Thompson et al. in Canadian population23. Lowest

agreement was seen in the Manning >3 versus

Manning >2 comparisons by k value of 0.301(95% CI:

0.201-0.401) in this study. Saito13 and Kay24

calculated k values of 0.72 and 0.76 respectively,

when comparing two or more Manning symptoms (no

pain required in the study of Kay et al.) with the

original Rome criteria (Rome-I). The results were

similar to the k value of present study (k-0.89). But

they found lower k-values of 0.2524 and 0.4313

compared to our k of 0.85 when comparing two or

more Manning with the revised Rome criteria (Rome-

II). From the data of present study it can be assumed

that nearly all the standard definitions (Manning >2,

Rome I and Rome II) are almost equally sensitive in

identifying IBS subjects in the urban community of

Bangladesh.

Conclusion

This study demonstrated that prevalence of IBS in

urban population of Bangladesh is similar to most

other recent population-based studies. Prevalence

estimates varied widely depending on the diagnostic

criteria used and we support the previous finding that

the prevalence of IBS is greatly influenced by how

the requirement for abdominal pain is defined. Rome-

I proved more sensitive than the Rome-II in the

community-based survey for diagnosing IBS.

Substantial to near perfect agreement was found

between different study definitions. There seems to

be little advantage in applying the new criteria in

clinical practice but more restrictive Rome-II criteria

are the most relevant to use in research. More

research is required and preferably with some

appropriate investigations to find out the exact

prevalence of IBS in urban population.

Acknowledgement

We would like to thank to Dr. Saidur Rahman

Mashreky, BMRC, Dhaka, Bangladesh for Statistical

analysis, Dr. Md. Nowfel Islam, Dr Shabnam Akhter

, Md. Shahidul Islam, Md. Shafiqul Islam and the

Habitants of ward-41, Dhaka City Corporation for kind

co-operation.

References

1. Thompson WG, Heaton KW. Functional bowel

disorder in apparently healthy people.

Gastroenterology 1980; 79: 283-288.

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BJM Vol. 21 No. 1 Comparative Prevalence of IBS Using Multiple Diagnostic Criteria

2. Stewart WF, Liherman JM, et al. Epidemilogy of

constipation (EPOC) study in the United States:

relation of clinical subtypes to socio-demographic

features. AM J Gastroenterol 1999; 94: 3530-3540.

3. Maxwel PR, Mandel MA, Kumar D. Irritable bowel

syndrome. Lancet 1997; 350: 191-195.

4. Masud MA, Hasan M, Khan AKA. Irritable bowel

syndrome in a rural community in Bangladesh:

prevalence, symptom pattern, and health care

seeking behaviour. Am J Gastroenterology 2001; 96:

1547-1552.

5. Raihan ASMA, Roy PK, Khanam M, Rahman MT,

Hasan M. Manning criteria in the diagnosis irritable

bowel syndrome in Bangladesh. Bangladesh J Med

1995; 6: 59-61.

6. Rahman M, Hasan M. Functional bowel disorders

in apparently healthy people. Bangladesh J Med

2001; 12: 105-112.

7. Jain AP, Gupta OP, Jajoo UN, Sidhwa HK. Clinical

profile of irritable bowel syndrome at a rural based

teaching hospital in Central India. J Assoc Phy India

1999; 39: 385-386.

8. Jones R, Lydeard S. Irritable bowel syndrome in

the general population. Bri Med J1991; 304: 87-

90.

9. Kay L, Jorgensen T, Jensen KH. The epidemiology

of irritable bowel syndrome in a random population:

prevalence, incidence, natural history and risk

factors. J Int Med 1994; 236: 23-30.

10. Talley NJ, Zinsmeister AR, Van Dyke C, Melton

LJ. Epidemiology of colonic symptoms and the

irritable bowel syndrome. Gastroenterology 1991;

101: 927-934.

11. Talley NJ, Phillips SF, Melton L J, Mulvihill C,

Wiltgen C, Zinsmeister AR. Diagnostic value of

Manning Criteria in irritable bowel syndrome.

Gut1990; 31: 77-81.

12. Boyce PM, Natasha A, Koloski BA, Talley NJ.

Irritable bowel syndrome according to varying

diagnostic criteria: are the new Rome II criteria

unnecessary restrictive for research and practice.

Am J Gastroenterol 2000; 95: 3176-3182.

13. Saito YA, Locke GR,III, Talley NJ, Zinsmeister AR,

Fett SL, Melton LJ, III. A comparison of the Rome

and Manning criteria for case identification in

epidemiological investigation of irritable bowel

syndrome. Am J Gastroenterol 2000; 95: 2816-2824.

14. Drossman DA, Li Z, Andruzzi E, Temple R, Talley

NJ, Thompson WG, et al. US householder survey of

functional gastrointestinal disorders: Prevalence,

socio-demography and health impact. Dig Dis Sci

1993; 38: 1559-1580.

15. Danivat D, Tankeyoon M, Srirataneban A.

Prevalence of irritable bowel syndrome in non-

western population. Br Med J 1988; 296: 1710.

16. Kapoor KK, Nigam P, Rastogi CK, Kumar A, Gupta

AK. Clinical profile of irritable bowel syndrome.

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17. Olubuyide IO, Olawuyi F, Fasanmade AA. A study

of irritable bowel syndrome diagnosed by Manning

criteria in an African population. Dig Dis Sci 1995;

40: 983-985.

18. Talley NJ, Boyce P, Jones M. Identification of

distinct upper and lower gastrointestinal symptoms

groupings in an urban population. Gut1998; 42:

690-695.

19. Talley NJ, Zinsmeister AR, Melton LJ. Irritable

bowel syndrome in a community: symptom

subgroups, risk factors and health care utilization.

Am J Epidemiol 1995; 142: 76-83.

20. Heaton KW, O’ Donnel LJD, Braddon FEM, Mountford

RA, Huges AO, Cripps PJ. Symptoms of irritable

bowel syndrome in a British urban community:

consulters and non- consulters. Gastroenterology

1992; 102: 1962-67.

21. Drossman DA, Mc kee DC, Sandler RS, Mitchell

CM, Crammer EM, Lowman BC, Burger AL

Psychosocial factors in the irritable bowel syndrome:

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with irritable bowel syndrome. Gastroenterology

1998; 95: 701-708.

22. Hamm LR, Sorrells SC, Harding JP, Northcutt AR,

Heath AT, Kapke GF, et al. Additional investigations

fail to alter diagnosis of irritable bowel syndrome in

subjects fulfilling Rome criteria. Am J Gastroenterol

1999;94: 1279-82.

23. Thompson WG, Irvine EJ, Pare P, Ferrazzi S, Rance

L. Functional gastrointestinal disorders in Canada.

First population-based survey using Rome II criteria

with suggestions for improving the questionnaire.

Dis Dig Sci 2002: 47: 225-235.

24. Kay L, Jorgensen T, Lanng C. Irritable bowel

syndrome: which definitions are consistent? J Int

Med 1998; 244: 489-494.

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Comparative Prevalence of IBS Using Multiple Diagnostic Criteria BJM Vol. 21 No. 1

Introduction:

Osteoarthritis (OA) is a leading cause of disability in

the elderly1. It is more common in women than in

men2. People with OA use health-care services at a

higher rate than a representative group of all

adults3,4,5. The number of people with OA disability

is expected to be doubled by the year 20206.

The goals of management of patients with

osteoarthritis are to control pain and swelling,

minimize disability, improve the quality of life, and

educate the patient about his or her role in the

management team. Management should be

individualized to the patient’s expectations, level of

function and activity, to the joints involved and the

severity of the patient’s disease, to occupational and

vocational needs, and to the nature of any coexisting

medical problems7.

EVIDENCE BASED NON PHARMACOLOGIC

MANAGEMENT OF OSTEOARTHRITIS: A REVIEW

ROWSAN ARA1, MD ZAHID ALAM2, MOHAMMAD FERDOUS UR RAHAMAN3, MONZOOR QUADER3,

JANNATARA SHEFA4

Abstract:

Osteoarthritis (OA) is a leading cause of disability in the elderly. The management of OA can be

divided into non pharmacologic interventions, pharmacologic interventions, and surgical options.

There are, at present, no specific pharmacologic therapies that can prevent the progression of joint

damage due to OA. Non pharmacologic therapies remain the main stay of management of OA patients.

There are varieties of conventional and non conventional non pharmacological options are available.

Among them, there is reasonably strong evidence of efficacy for exercise programs, weight loss,

patient education, and wedged shoe insoles is available.

Key words: Osteoarthritis, non pharmacologic therapy, management.

1. MD (Rheumatology) final part student, Bangabandhu Sheikh Mujib Medical University, Dhaka.

2. Junior consultant, Cardiology, BIRDEM, Dhaka

3. Medical Officer, Dept of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka.

4. Lecturer, Department of Community Medicine, Enam Medical College, Dhaka.

The management of OA can be divided into non-

pharmacologic interventions, pharmacologic

interventions, and surgical options. There are, at

present, no specific pharmacologic therapies that

can prevent the progression of joint damage due to

OA.

This review will discuss available evidences for non

pharmacologic management of osteoarthritis.

Non pharmacologic therapy:

There are varieties of conventional and non

conventional non pharmacological options are

available (Table 1)8. Among them, there is reasonably

strong evidence of efficacy for exercise programs,

weight loss, patient education, and wedged shoe

insoles is available for knee OA 9.

Table-I

Non pharmacolgic Management of Osteorarthritis

Conventional Options Unconventional Options

Patient education Transcutaneous electrical nerve stimulation

Arthritis self-help courses Pulsed electromagnetic fields

Weight loss Static magnets

Temperature modalities Acupuncture

Exercise Spa therapy

Orthotics Yoga

Modified activities of daily living

Bangladesh J Medicine 2010; 21 : 41-45

REVIEW ARTICLES

Patient Education and Psychosocial Support:

Patient education is an important first step in OA

therapy. The patient should be an integral part of the

decision-making team. To do this effectively, the

patient should understand the nature of OA, including

its natural history and treatment options. Some

patients may develop significant emotional

disturbances related to the pain and changes in

normal daily activities. These may include mood

disorders, such as depression, or sleep disorders8.

The patient evaluation should include an assessment

of current coping mechanisms such as activity

avoidance and denial. Some authors have suggested

that the impact of psychosocial support may be as

substantial as that of medical therapy. As an

example, regular reinforcement of management issues

with patients by telephone has been associated with

decreased joint pain and increased functional

status10,11,12. A meta-analysis of self-management

for OA of the knee in 2006 concluded that such

interventions produced significantly better psychologic

outcomes than those achieved by control subjects13.

However, pain and function may not be substantially

improved by instruction in self-management14.

Weight loss:

Obesity is an important risk factor in the development

of OA of the knee15,16. One study noted an increased

risk of developing OA of the knee in patients with

high body mass indices (1.5 and 2.1 for men and

women, respectively) 17. In a follow-up study using

the same population, the risk of developing OA was

reduced following weight loss; a ten-pound weight

loss over 10 years decreased the odds for developing

knee OA by 50 percent18.

Regimens of weight loss and exercise have been

associated with improvement in pain and disability

in OA of the knee19. In addition to reducing the risk

of progression of OA, weight loss of even modest

degree, may produce improvement in joint pain and

function. In a prospective study 316 overweight people

with symptomatic and radiographic OA of the knees

were randomly assigned to one of four groups: diet

alone, exercise alone, diet and exercise, or education

in healthy living. The combination of diet and exercise

was the most effective and was associated with

decreased knee pain and improved self-reported and

measured function20. Another study suggested that

a reduction in the percentage body fat, rather than

weight, may be significant in reducing pain from OA

of the knee21. The symptom-relieving effects of weight

loss have been shown to last as long as 1 year22.

Temperature modalities:

Heat and cold modalities have been used for many

years in the treatment of OA despite the paucity of

adequate controlled, randomized clinical studies.

Moist superficial heat can raise the threshold for

pain23, produce analgesia by acting on free nerve

endings24, and decrease muscle spasm25.

Warm applications can be in the form of warm soaks

or heating pads. Individual sessions should not

exceed a temperature of 45°C or last more than

approximately 30 minutes26.

Exercise

An appropriate exercise program is an integral part

of the optimal, multidisciplinary management of OA.

The relationship between exercise and arthritis has

been the subject of considerable controversy. This

issue has been well addressed in two large,

randomized trials of the impact of exercise on the

disability associated with OA. In one study, 102

patients with documented OA of one or both knees

were randomized to receive either a combined program

of supervised fitness walking and education or routine

medical care and telephone contact showed that a

program of supervised fitness walking and patient

education can improve functional status without

worsening pain or exacerbating arthritis-related

symptoms in patients with osteoarthritis of the

knee27. “The Fitness Arthritis and Seniors Trial

(FAST)” compared the impact of 18 months of aerobic

exercise, resistance exercise, or a health education

program on several measures of disability, physical

performance, and pain in elderly subjects with OA of

the knee concluded that older disabled persons with

osteoarthritis of the knee had modest improvements

in measures of disability, physical performance, and

pain from participating in either an aerobic or a

resistance exercise program and exercise should be

prescribed as part of the treatment for knee

osteoarthritis28.

A systematic review of randomized clinical trials,

which investigated the effectiveness of exercise

therapy for OA of the hip or knee, concluded that,

there is evidence of modest benefits from exercises29.

Meta-analyses of randomized trials focused on OA of

the knee, appeared in 2006 and 200913, 30. The authors

of the meta-analyses concluded that exercise

regimens for patients with OA of the knee led to

improved physical health and an at least short term

beneficial effect on OA. Home-based exercise

interventions also significantly improve symptoms in

those with knee OA 31.

42

Evidence Based Non Pharmacologic Management of Osteoarthritis: A Review BJM Vol. 21 No. 1

Patients with moderate to severe OA may not have

as much symptomatic benefit from exercise as those

with mild disease. This was illustrated in a study

that randomly assigned middle aged adults with

symptomatic and radiographically apparent (grade III

of IV) OA of the knee to aerobic exercise or to no

intervention. After six weeks there were no significant

differences between groups in knee pain or function.

Self-reported quality of life was significantly better

in those who exercised and this difference persisted

for up to six months, at which time observations were

ended32.

Orthotics and Bracing

Orthotics ranging from insoles to braces can be

effective in providing symptomatic relief and are

probably underused by most physicians. Studies have

demonstrated that lateral wedged insoles provide

substantial relief to those with medial compartment

knee OA, particularly those with varus deformity33.

In some studies, those with milder symptoms

obtained greater benefit34. Knee braces have been

evaluated as well. Valgus bracing of patients with

medial compartment OA can reduce pain and increase

levels of activity35. In one study, medial taping of the

patella reduced the pain of those with patellofemoral

compartment OA by 25%36.

Heel lifts have been tried in those with hip OA. In

one uncontrolled study, most patients reported

diminished symptoms. Time to improvement

lengthened with the radiographic stage of OA37. Those

with carpometacarpal joint arthritis should initially

be offered conservative management, including the

use of splints. In one trial, 70% of patients treated

with a 7-month intervention that included the use of

splints were able to improve their symptoms

considerably and avoid surgical intervention38.

The appropriate use of a cane can be an important

adjunct, particularly in OA of the hip. It has been

estimated that a cane can provide up to a 40%

reduction in hip contact forces during ambulation39.

The cane should be used in the hand contralateral to

the affected hip or knee40 and should be advanced

with the affected limb while walking. The appropriate

cane size is that which results in about a 20-degree

flexion of the elbow during use41.

Modification in Activities of Daily Living

Physician advice and occupational therapy can provide

useful insights into modifications of daily activities

to reduce OA symptoms. These interventions can

range from using an elevated toilet seat or shower

bench in someone with lower extremity OA to using

appliances designed to open jars in patients with

hand OA. Assistance from occupational therapists

can be valuable8.

Transcutaneous electrical nerve stimulation (TENS)

A double-blind, randomized, controlled study of 78

patients with knee OA found that daily TENS for four

weeks resulted in significant short-term improvement

in knee pain, flexion, and duration of morning

stiffness42. A double-blind, cross-over trial of 36

patients with knee OA was unable to confirm a positive

response to TENS 43. TENS use for 3 weeks was

compared with 3 weekly hyaluronic acid injections in

60 patients with OA of the knee. Pain relief was

observed in both groups through the 6 months of

follow-up44.

Pulsed electromagnetic fields:

Pulsed electromagnetic fields have been tested in

double-blind, placebo-controlled trials. In one study,

a primary end point of pain reduction was not

achieved45. Another study did not meet its primary

end point but reported an improvement in knee

stiffness in subjects younger than 65 years, without

an accompanying reduction in pain46.

Static magnets:

In one double-blind, randomized, placebo-controlled

trial of 43 patients, the WOMAC pain and physical

function subscales, along with a 50-foot walk,

demonstrated a statistically significant benefit of

static magnets at 2 weeks47. Another 29-patient

double-blind, placebo-controlled trial in knee OA

reported a benefit over placebo after 4 hours of use,

but there were no significant differences between

groups at 6 weeks of continued treatment48.

Acupuncture:

Early clinical trials49, 50 and one literature review51

concluded that acupuncture shows promise in the

treatment of knee pain from OA.

Spa therapy:

Spa therapy also has advocates. It has been touted

for low back pain and for lower extremity OA52.

However, randomized, controlled studies are

lacking53.

Yoga:

Yoga has also shown some symptomatic benefit in

OA of the hands, based on limited testing54.

Conclusion:

The treatment of OA includes a variety of possible

non-pharmacologic and pharmacologic interventions.

This review discusses only evidences of non

pharmacologic aspect of management. Treatment

43

BJM Vol. 21 No. 1 Evidence Based Non Pharmacologic Management of Osteoarthritis: A Review

should be tailored to the individual and consists of a

combination of modalities. These provide symptom

relief but have no proven effect on the progression of

disease. Structure and disease modification has yet

to be achieved in OA. Trials that are under way could

determine whether this is a realistic goal.

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45

BJM Vol. 21 No. 1 Evidence Based Non Pharmacologic Management of Osteoarthritis: A Review

FEEDING PRACTICE AMONG ANEMIC AND NON-

ANEMIC INFANTS AND YOUNG CHILDREN IN A

SELECTED RURAL AREA

MITHUN ALAMGIR1, JANNATARA SHEFA2, KHAN SHAKIL AHMED3, SHAFINAZ GAZI4, MOHAMMAD

FERDOUS UR RAHAMAN5, MD. ABUL KALAM AZAD6

Abstract:

Background: Iron deficiency is a major public health problem worldwide especially in developing

countries. It is now a major public health problem in Bangladesh & leading cause of morbidity and

mortality of in young children (6-23months). Recent surveys in Bangladesh show very high prevalence

figures of anemia ranging from 70%-90% among young children.1 Objective: To find out the feeding

practice among the anemic & non anemic infants (6-11months) & young children (12-23months) in

rural Bangladesh. Methods: This cross sectional comparative study was conducted on purposively

selected anemic and non-anemic 150 infants and young children residing in a rural area (Village:

Shadapur, Thana: Nowabgonj) of Bangladesh to determine the association between feeding practice

and anemia status. Infants ranging from 6-11 months & children ranging from 12-23 months were

the enrollment criteria for the study. Pre tested structured questionnaire was used to collect the

data from parents & anemia status was determined by the field level Spectrophotometer. The test

statistics used to analyze the data were descriptive statistics and Chi-square (χ2) test.

Result: Of the 150 children in the study, 77(51.3%) were infants and the rest 73(48.7%) were

young children. Among the breast fed (67%) babies nearly 74% was fed on demand, the rest 26%

was given scheduled feeding. 60% of the respondents started complimentary feeding from 6

months, 26.7% before 6 months and 13.3% after 6 months. 53.3% of the respondents followed

standard guideline (WHO/UNICEF guidelines) in feeding their babies. The prevalence of anemia

was 55.3% in 6 – 23 months children. The prevalence of anemia was a bit higher in the infants then

young children. Breast-fed on demand was found to be significantly higher in non-anemic infants.

About 85% non-anemic infants & 90% children were given WHO/UNICEF guidelines in giving

complementary food. Conclusions: the best solution as it is evident from the present study that

anemia was significantly less prevalent among children whose mothers followed the guideline than

those children whose mothers did not follow it.

1. Assistant Professor, Department of Community Medicine, Enam Medical College, Dhaka.

2. Lecturer, Department of Community Medicine, Enam Medical College, Dhaka.

3. Assistant Professor, Department of Forensic Medicine, Enam Medical College, Dhaka.

4. MS student, Department of Anatomy, Bangabandhu Sheikh Mujib Medical University, Dhaka.

5. Medical officers, Department of Medicine, BSMMU, Bangabandhu Sheikh Mujib Medical University, Dhaka.

6. Associate professor, Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka.

Introduction:

Iron deficiency is a major public health problem

worldwide especially in developing countries. There

are about 2 million individual are affected by various

types of anemia, most of them are in IDA (Iron

deficiency anemia) in developing countries. It is now

a leading cause of morbidity and mortality of in young

children. Anemia is a major public health problem in

Bangladesh; under 6-23 months aged children are the

most vulnerable group. Recent surveys in Bangladesh

show very high prevalence figures of anemia ranging

from 70%-90% among young children.1 The last

anemia survey in Bangladesh describes in 6-11

months children 76% are anemic. In 12-23 months

the prevalence is 58%.2 In rural area, 61% children

are anemic as compared to 73% in urban area, in age

group 6-23 months.

In country like India, Nepal and Sri Lanka the

prevalence of IDA also high in this group (India 77%,

Nepal 88%, Srilanka 55%).3

Improper feeding, early weaning, insufficient breast

feeding, low birth weight etc are the main cause of

IDA in children 6-23 months of age. In these age

group children cannot depend on breast milk alone

to meet their iron requirements.

Bangladesh J Medicine 2010; 21 : 19-24

Generally IDA is due to two of bioavailability of dietary

iron and large loss of iron from the body. Food

containing ascorbic acid (Vitamin C) and heam iron

increase absorption of iron from whole meal. Ascorbic

acid is very important for absorption of non-heam

iron. National nutrition survey in Bangladesh showed

dietary iron is quite high in poor but 86% was

anemic.4

For infant and young children, IDA has potentially

irreversible effect on cognitive motor and language

development, future learning capacity, school

performance and immunity.

Proper feeding and caring practice has a role on IDA

of children. WHO suggested that after exclusive

breast feeding up to 4-6 months of life the evolving

nutritional requirements of infants should be met by

nutritionally adequate and safe complementary feed

while breast feeding continues for up to 2 years of

age as beyond. However in developing countries giving

a hygienic food to a baby is sometimes difficult in

poor society can increase their risk of infection. In

these cases WHO recommend exclusive breast feed

up to 6 months of age and after that proper caring

practice is needed to caring a child.

The cause of high prevalence of IDA in 6-23 months

of age is defective feeding practice. 6-23 months

children cannot depend only on breast milk alone. To

meet their iron requirements WHO and UNICEF have

suggested that 6 months old infant should give in

addition of breast milk, frequent small complementary

meal that rich in energy, protein and micronutrients.

However, survey show that while breast-feeding is

generally continued well into the second year of life,

infants are given food that rarely contains item supply

adequate nutrients.5 In addition complementary food

is heavily shaded with cereal that contains high

amount of phytates, which is a potent iron absorption

–inhibitor. This makes infants highly susceptible to

IDA. In developing countries 39% children were given

complementary feeding from 4 months age, that is

early weaning, which is also a risk factor of IDA. 41%

of infants aged over 6 months are fed virtually nothing

else but breast milk until the age of 2 years, which is

late weaning and another risk factor of IDA. Apart

from these feeding problems the young children are

affected by worm infestation of poor hygiene one of

the important factors of caring practice. Helminthes

infection is also a major cause of IDA in young

children. Globally food fortification as iron

supplementation has proven to be a useful strategy

to address the IDA. WHO has recommended blanket

supplementation, without screening in all children

6-24 months of age.5 Education and treatment of

infection are given more importance in developing

countries.

It is evident in several studies that an Iron

intervention has rarely been effective due to a number

of reasons, mainly low compliance. It can result in

gastric irritation and abdominal discomforts.

Methods and Materials:

Study design

Cross Sectional Comparative study.

Study place

Village: Shadapur, Thana: Nowabgonj, District: Dhaka.

Study population

Infants and young children of selected rural area of

Bangladesh.

Study period

March – June’2007

Sample size

Purposively 150 samples have been taken from study

area.

Sampling Technique

Purposive sampling technique (Non Probable)

Ethical implication

As the study was conducted in a rural area, first of

all a written permission was taken from the local

authority. Then both verbal and written consent was

taken from the respondent parents.

Data Collection instrument

A questionnaire was prepared as a research

instruments in such a way that the interview could

flow as naturally as possible. They were designed

according to objectives of the study and were made

simple and easily understandable manner. The

questionnaire was pre-tested on a small number of

respondents at Keranigonj, Dhaka similar to the

study population to identify and difficulty for

understanding by the respondents. Then modified and

finalized the questionnaire for data collection.

Data collection technique

The purpose of the study was explained to the local

authority and to the respondents. Data was collected

from respondent through face to face interview by

using the Bangla pre-tested structured questionnaire.

To determine the anemia status blood was collected

from the baby by field level spectrophotometer.

Data processing and analysis

After completion of data collection data were

processed and edited manually to reduce error. Both

descriptive and analytical statistics were done by

SPSS (11.5 version)

20

Feeding Practice among Anemic and Non-Anemic Infants and Young Children BJM Vol. 21 No. 1

Selection criteria

For anemic inclusion:

1. Study population was within 6 – 23 months of

age

2. Hemoglobin level bellow 11 gm/dl

3. Free from any acute or chronic illness

4. Parents willing to participate

For non-anemic inclusion:

1. Study population was within 6 – 23 months of

age

2. Hemoglobin level equal or more than 11 gm/dl

3. Free from any acute or chronic illness

4. Parents willing to participate

Results:

The findings of the study intended to investigate the

association between anemia and feeding practice of

infants and young children are documented below.

Of the 150 children participated in the study,

77(51.3%) were infants ranging from

6 – 11 months and the rest 73(48.7%) were young

children ranging from 12 – 23 months. Fig. 1 shows

the distribution of the children by sex. Males and

females were almost equally distributed giving a male

to female ratio of roughly 1:1.

Table II shows the educational status of parents’ of

participating children. About 23% of the fathers were

illiterate, 13% primary level educated, 13.7%

secondary level educated, 35.1% SSC to HSC level

educated and 15.3% graduate and higher level

educated. In terms of mothers’ education, 35.3% were

illiterate, 18% primary, 14.7% secondary, 24.7% SSC

to HSC and only 7.3% graduate and postgraduate level

educated.

Table III shows the distribution of the respondents

by feeding practice of their babies. Two-third (66.7%)

the babies were breast fed. Of the breast fed babies

nearly three-quarter (74%) was fed on demand, while

the rest (26%) was given the same 2 times daily. Sixty

percent of the respondents informed that they started

complimentary feeding from 6 months, 26.7% before

6 months and 13.3% after 6 months. Over half (53.3%)

of the respondents followed standard guideline

(WHO/UNICEF guidelines) in feeding their babies.

About 75% of the mothers of breast-fed infants and

59.5% of mothers without breast-fed infants gave e”

3 and e” 5 complimentary feeds (CF) respectively in

24 hours, while 70.3% of the mothers of young

children gave 5 or more CFs in 24 hours.

Fig. 2 demonstrates age-wise distribution of anemia

among children ranging from 6 – 23 months. The

prevalence of anemia was 55.3%in 6 – 23 months

children. The prevalence of anemia was a bit higher

in the infants (6 – 11 months) compared to the young

children (12 – 23 months).

Table IV shows the association between breast feeding

status and anemia in infants. Anemia was not found

to be associated with whether the baby was breast-

fed or not (p = 0.918). Table V shows the association

between frequency of breast feeding and anemia in

infants. Breast-fed on demand was found to be

significantly higher in non-anemic infants (90.5%)

than that in anemic infants (66.7%) (p = 0.046).

Table VI shows the association between

complimentary feeding related variables and

development of anemia in young infants. More than

80% of the non-anemic infants were given

complimentary feeding from 6 months compared to

37.8% of the anemic infants (p = 0.001). About 85%

of the mothers of non-anemic infants followed

standard guidelines (WHO/UNICEF guidelines) in

giving complimentary feeding to their babies as

opposed to 26.7% of the mothers of anemic infants

(p < 0.001).

Table I

Distribution of the study children by age (n = 150)

Age (months) Frequency Percentage

Infant (6 – 11 months) 77 51.3

Young children

(12 – 23 months) 73 48.7

Fig.-1: Distribution of the children by sex (n = 150)

21

BJM Vol. 21 No. 1 Feeding Practice among Anemic and Non-Anemic Infants and Young Children

Table II

Distribution of children by parents’ educational status

Parents educational status Frequency Percentage

Fathers’ education

Illiterate 30 22.9

Primary 17 13.0

Secondary 18 13.7

S.S.C & H.S.C 46 35.1

Graduate & above 20 15.3

Mothers’ education

Illiterate 53 35.3

Primary 27 18.0

Secondary 22 14.7

S.S.C & H.S.C 37 24.7

Graduate & above 11 7.3

Table III

Distribution of the respondents by baby feeding

practice

Feeding practice Frequency Percentage

Baby breast fed (n = 150)

Yes 100 66.7

No 50 33.3

Frequency of breast feeding (n = 100)

Feeding on demand 74 74.0

Scheduled feeding 26 26.0

Complimentary feeding started (months)

< 6 40 26.7

From 6 90 60.0

> 6 20 13.3

WHO/Unicef guidelines followed

Yes 80 53.3

No 70 46.7

Frequency of CF* in infants with BF**

< 3 14 25.6

³ 3 40 74.1

Frequency of CF in infants without BF

< 5 15 40.5

³ 5 22 59.5

Frequency of CF in young children

< 5 22 29.7

³ 5 52 70.3

* CF = Complimentary feeding;

**BF = Breast feeding

Table-IV

Association between breast feeding status and anemia

in infants

Breast feeding Status of anemia p-

status# Anemic Non-anemic value

(n = 45) (n = 30)

Breast-fed 32(71.1) 21(70.0) 0.918

Not Breast-fed 13(28.9) 9(30.0)

# Data were analyzed using Chi-square (χ2) Test.

Figure in the parentheses denoted corresponding percentage.

Table-V

Association between frequency of breast feeding and

anemia in infants

Frequency of breast Status of anemia p-

feeding# Anemic Non-anemic value

(n = 33) (n = 21)

Feeding on demand 22(66.7) 19(90.5) 0.046

Scheduled feeding 11(33.3) 2(9.5)

# Data were analyzed using Chi-square (χ2) Test.

Figure in the parentheses denoted corresponding percentage.

Table VI

Association between complimentary feeding and anemia

in infants

Complimentary Status of anemia p-

Feeding Anemic Non-anemic value#

(n = 45) (n = 32)

Complimentary feeding started#

Below 6 months 19(42.2) 5(15.6)

From 6 months 17(37.8) 9(20.0) 26(81.3) 0.001

After 6 month 1(3.1)

Standard guide-line followed Yes

No 12(26.7) 27(84.4)

33(73.3) 5(15.6) < 0.001

# Data were analyzed using Chi-square (χ2) Test.

Figure in the parentheses denoted corresponding percentage

Fig. 2: Distribution of respondents by anemia (n = 150)

22

Feeding Practice among Anemic and Non-Anemic Infants and Young Children BJM Vol. 21 No. 1

Discussion:

The present study showed that 55.3% of 6 – 23 months

children were anemic. The prevalence of anemia was

a bit higher in 6 – 11 months infants (58.4%)

compared to

12 – 23 months children (52.1%). Recent survey in

Bangladesh shows very high prevalence of anemia

ranging from 70% - 90% among young children.1 The

last anemia survey in Bangladesh described 76% of 6

– 11 months children and 58% of 12 – 23 months

children as anaemic.2 In rural area 61% of children

are anemic in the age group of 6 – 23 months. In

country like India, Nepal and Srilanka the prevalence

of IDA are also high in these age group (India-77%,

Nepal-88%, Srilanka-55%).3 As of feeding practice,

two-third (66.7%) the babies were breast-fed. 60% of

the mothers started complementary feeding from 6

months, 26.7% before 6 months and 13.3% after 6

months. About 75% of the breast-fed infants and 60%

of non breast-fed infants were given e” 3 and e” 5

complementary feeds (CFs) respectively in 24 hours,

while 70.3% of the mothers of young children gave 5

or more CFs in 24 hours. Over half (53.3%) of the

mothers followed standard guideline (WHO/ UNICEF

guidelines). A nationwide community based cross

sectional study was conducted in Bangladesh on a

representative sample of 3049 children of 0-2 years

and on their mothers showed that half of the mothers

initiated breast feeding more than 1 hour after birth.

Prevalence of exclusive breast feeding among 6 months

and or below was 61%. More than half (50.8%) of the

children were given complementary feeding before 4

months and about 40% at 4 – 5 months of age. Among

1463 infants of 6-11 months, 51.4% were given 3 feeds

a day. Among 506 children 12 – 24 months over 56%

were given 3 feeds a day. It was reported that about

95% of the children of one year of age and 82.7% of

two years of age were breast fed throughout. About

2.8% of the children were suffering from severe

nutritional deficiency disorder and 14.1%-18% were

suffering from moderate nutritional deficiency disorder

respectively.6 The findings are consistent with the

findings of the present study. Contrary to these

findings that majority (97.8%) of children was

breastfed but only 10.4% of them were exclusively

breastfed up to 6 months. Weaning was started at

the age of 6 months in about 20% cases. 50%

continued breast feeding for a period 1-2 years.7

A hospital based analytic study was conducted in

Brisbane Australia in the year 2001; Data were

obtained from records held at Maternal and Infant

Health Clinics in the cities of Brisbane (population

100000). 80-90% of mothers brought their infants to

the clinics after 6 months of delivery. On the first

visit to the clinic social, family, feeding practice

history were recorded. At each subsequent visit, the

data, presents weight and feeding of the infant and

young children, status of health (especially anemia)

was assessed. Percentage of breast feeding at first

visit and subsequent 2 visits after 6 months was 67%,

68% and 69% which is fairly comparable to the

findings of the present study. Prevalence of anemia

after 6 months was 30%, almost that found in our

study (58.5%). Those who practices breast feeding as

well as proper complementary feeding (according to

hospital guideline), rate of anemia was only 10% which

is also much less compared to our sampled

population with similar characteristics. Rest of 20%

was among those who did not practice breast feeding,

complementary feeding regularly. The data of infants

and young children, who attended the Maternal and

Infant Health Clinics for 2 years, were used to test

the relationships of infant breast feeding with secular

trend and social class at 6-11 months and 12-23

months. At each of these age group, there was a highly

significant (p < 0.001) increase in the level of breast

feeding from 1982 to 1993. In the 1982 data, there

was a trend for more primiparous and upper class

mothers to breast feed during the first three months

than multiparous and lower class mothers but this

trend did not show the statistical significance. In

1993, the general prevalence of breast feeding had

increased and same trends were present. This study

showed that there has been a marked increase in

the prevalence of breast feeding amongst mothers so

that rate of nutritional anemia has been decreased a

lot.8

The prevalence of anemia among the infants who were

breast fed on demand was significantly less compared

to the scheduled breast feeding. The infants who were

given complementary feeding according WHO

guidelines were also less anemic compared to those

who did not follow the guideline meaning that it is a

standard one to prevent the infants being anemic.

The same was found true for young children too. The

findings of the study also revealed that time of starting

complementary feeding is also no less important,

because prevalence of anemia was significantly less

among the children who were given complementary

feeding from 6 months as opposed to those who were

given earlier or later than 6 months. However, feeding

the babies according to WHO/ UNICEF guidelines

was much lower which might be one of the reasons

of more than half of the infants and young children

(53.3%) being anemic. The guideline that WHO and

UNICEF recently endorsed as Global Strategy for

infant and young child feeding is to fulfill all the

23

BJM Vol. 21 No. 1 Feeding Practice among Anemic and Non-Anemic Infants and Young Children

nutrients needed by the growing children and also to

protect them from vicious cycle of malnutrition and

infection. Once some of the determinants of good

nutrition are not fulfilled, children start to suffer from

malnutrition and nutritional deficiency anemia. When

foods other than milk are introduced into the infant

diet, the situation is more complex because these

foods vary considerably in protein content and protein

quality within same country and among different

countries. Furthermore amount of weaning food

consumed and amount of milk consumed varies

among individuals. Most of the international

recommendation use protein: energy ratio (P: E) when

assessing the protein quality of weaning food. There

is assumption also in these calculations because both

the safe level of protein intake and the mean

requirement of energy at each age are included. As it

is mentioned that different country has different

feeding practice so worldwide WHO guideline is

acceptable. WHO shows the requirement of accurate

protein, energy and calorie requirement for specific

age group9.

Conclusion & Rcommendations

It has already been reflected in the discussion that

the children from 6 months onward become more

vulnerable to develop anemia because of increased

physiological demand for iron to form hemoglobin.

The mothers should therefore give their babies ideal

combination of complementary feeds along with breast

feeding. After the first year, though the daily need of

iron slightly decreased, 0.5 mg of iron still needed

each day until the end of two years. So the children

at this age too are at greater risk of developing anemia

fortifying further the need of complementary feeding

and continuation of breast feeding. At these two age

groups (6-11months and 12-23months) as iron demand

to be fulfilled from the exogenous source

complementary feeding to be given to the children

must be scientifically sound both in terms of

frequency and content. As long term iron therapy and

the intake of iron fortified food have got the deleterious

effect on the health, it is better avoiding them unless

otherwise indicated. Since feeding practice varies from

culture to culture, following WHO/UNICEF guideline

could be the best solution as it is already evident

from the present study that anemia was significantly

less prevalent among children whose mothers

followed the WHO/UNICEF guideline than those

children whose mothers did not follow it.

In the light of findings of the present study and

discussion thereof, the following recommendations

are put forward

1. Mothers should breastfed their babies on demand

and should be exclusive for the first 6 months.

2. Complementary feeding should be started at

completion of month 6 along with breast feeding.

3. Mothers must prepare the complementary feeds

in accordance with WHO/Unicef guidelines.

4. The diet should be rich in energy dense bioavailability

iron to prevent child from being anemic.

5. Mothers should be discouraged to give iron in

the form medication or food fortified with iron as

it carries the risk iron poisoning.

References

1. Andre B, Nicole D, Elaine F. Nutritional Survey

Report of HKI/IPHN .1999; 3-4.

2. Juergen M, Erhardt N. Nutritional Survey Report of

HKI/IPHN.2001; 120-122.

3. Allen P, Ana NS, Walsh KH Reports of PHNI/MEDS/

USAID. 2003; 34-38.

4. Hasan MN, Shakur D. Survey Report of BBS. 2004;

89-92.

5. Akre J, Black KH, Cohen RJ. WHO Nutritional

Survey Report. 2001; 24-36.

6. Hannan A. Rahman F. Surveillance on breastfeeding

and weaning situation & Child and maternal health

in Bangladesh. Report of 12th round survey. 2007;

94-95.

7. Azeem M, Rahman H. Breast feeding practice among

mothers working in a selected garment factory in

Tongi. Journal of Achieving Millennium

Development Goals 4 and 5. 2007; 203-204.

8. Eaton-Evans j, Townsend B, Dugdle A. The milk

feeding of infants in south-east Queensland.

Journal of Food and Nutrition.1985; 137 – 141.

9. Raiha, Axelsson. Journal of Follow-on Formula.

2000; 26-30.

10. Roeser HP. Iron. Journal of Food and Nutrition

.1986; 82 – 91.

11. Polhamus B, Dalenius k, Thompson D. Paediatric

Nutrition Surveillance. Nutrition in Clinical

Care.2003; 6: 132 – 134.

12. Thomas c. The Amaemia of Inflammation. Padiatric

Haematology.1996;43: 40-44.

13. Thomas A. A common cause of childhood Anaemia.

Paediatric Haematology.1994; 42: 20-23.

14. Sean R, Roy D. Deliberations and Evaluation of the

Approaches, Endpoints and Paradigms for Iron

Dietary Recommendation. American Institute of

Nutrition 1996; 2404 – 2409.

15. Roy SK, Chakrabarty B. Complimentary Feeding.

Report of 1st National conference on achieving MDG

.2007; 34-35.

16. Islam T, Roy S, Afsa N. Identification of inappropriate

feeding practice of children among selected slam

dwellers of Dhaka city. Report on 1st National

conference on achieving MDG.2007; 111-112.

17. Nazrul I. Report of National Nutritional Survey in

Bangladesh. 1993; 65-70.

24

Feeding Practice among Anemic and Non-Anemic Infants and Young Children BJM Vol. 21 No. 1

Introduction

Periodontitis is an infection of the tissues that hold

the teeth in place. In periodontitis, plaque builds

and hardens under the gums. The gums pull away

from the teeth, forming “pockets” of infection. The

infection leads to loss of the bone that holds the

tooth in its socket and might lead to tooth loss. There

are often no warning signs of early periodontitis. Pain,

abscess, and loosening of the teeth do not occur until

the disease is advanced. Since periodontitis affects

more than just the gums, it cannot be controlled with

regular brushing and flossing. Periodontitis should

be treated by a periodontist (a gum disease specialist)

or by a general dentist who has special training in

treating gum diseases.

Diabetes mellitus is a systemic disease with

several major complications affecting both the

quality and length of l i fe. One of these

complications is periodontal disease (periodontitis).

Periodontitis is much more than a localized oral

infection. Recent data indicate that periodontitis

may cause changes in systemic physiology. The

interrelationships between periodontitis and

diabetes provide an example of systemic disease

predisposing to oral infection, and once that

infection is established, the oral infection

exacerbates systemic disease.

Material and methods

This was a prospective cross-sectional study carried

out during the period of July’07 to June’08. Two

ORAL HYGIENE AMONG TYPE 2 DIABETES PATIENTS:

A STUDY OF 276 CASES

KULSUM UMME1, MAHMUD A2, AZAM MG3, AHMED JU4, NAZIMUDDIN K5

Summary

It is thought that poor oral health is associated with type 2 diabetes mellitus (DM). There has been

relatively little data to date concerning oral health and periodontal disease with glycaemic status

among DM patients in our country. The purpose of this cross-sectional study was to investigate the

oral hygiene and periodontal status among type 2 diabetes patients and found that dental caries

and periodontitis are strongly associated with poorly controlled of DM.

1. Asociate Professor, Dhaka Dental College, Dhaka

2. Medical officer GHPD BIRDEM, Dhaka

3. Senior research Officer, GHPD, BIRDEM, Dhaka

4. Register Medicine ll, BIRDEM, Dhaka

5. Professor of Medicine BIRDEM, Dhaka

hundred and seventy six patients with type 2 DM

were studied. Clinical data like periodontitis,

gingivitis, dental carries, oral ulcer, periodontal

abscess were examined and baseline

characteristics were recorded. Fasting plasma

glucose (FPG), 2-h post-prandial glucose (PPG),

glycated haemoglobin (HbA1c) were estimated. The

mean of glycosylated hemoglobin measurements

(HbAlc) was used to indicate the long-term control

of DM. The study participants were divided into

well- (HbAlc <7%) and poorly- (HbAlc >7%)

controlled diabetics.

Results

Fig.-1: Patients with Periodontitis (n=101) and their

glycemic status

Bangladesh J Medicine 2010; 21 : 34-36

Of the 276 patients 141(51.0%) were male, age was

53.6 ± 10.9 years. Duration of DM was 9.6 7.1

years. The percentage of periodontitis, dental

carries, gingivitis, periodontal abscess, oral

candidiasis, glossitis, oral ulcer and leukoplakia

were 37.0%, 32.2%, 5.1%, 1.4%, 1.4%, 1.1%, 1.1%

and 0.7% respectively. A significantly increased

frequency of dental caries with poorer control of

diabetes was observed (p<0.001). The extent of

periodontitis also increased with poorer control

(p<0.001).

Discussion

In chronic periodontitis, the tooth supporting

structures (alveolar bone and the periodontal

ligament) are destroyed. The disease has a

multifactorial origin. Complexes of commensal oral

anaerobic bacteria and perhaps viruses are thought

to interact with risk factors, such as smoking,

diabetes and depression, to create the conditions

which make a person susceptible to periodontitis.

The patient’s immuno-inflammatory response to the

bacteria causes the tissue destruction which occurs

in chronic periodontitis.

It is useful to distinguish chronic gingivitis from

periodontitis. Chronic gingivitis is the very common

inflammatory reaction occurring in the gingival

tissues in response to the accumulation of dental

plaque. It usually precedes the development of

periodontitis, but chronic gingivitis does not

inevitably progress to periodontitis.

The relationship between diabetes, gingivitis and

periodontitis

Although periodontitis is a recognised complication

of diabetes, people with well-controlled diabetes who

have good oral hygiene are not at increased risk of

periodontitis. However, their susceptibility to

periodontitis is significantly increased when their

diabetes is poorly controlled, particularly if they also

smoke. Recent epidemiologic evidence shows that

the prevalence of diabetes in patients with

periodontitis is significantly greater (by two times)

than in people without periodontitis. The gingival

and periodontal signs which may alert the clinician

that the patient has previously undiagnosed diabetes

or that the patient’s diabetes is poorly controlled,

include:

• persistence of gingival inflammation after standard

periodontal treatment (thorough supra-and

subgingival scaling and cleaning, oral hygiene

instruction)

• severe gingival inflammatory response to plaque

and proliferation of gingival tissues at the gingival

margin

• continuing alveolar bone loss despite periodontal

treatment (fig. 3)

• simultaneous formation of multiple periodontal

abscesses fig. 4)

Fig.-2: Disease frequency of patients (Periodontitis -

37.0%)

Fig.-1: Patient with poorly controlled diabetes shows

extensive alveolar bone loss involving most teeth. The

destruction of bone has been rapid even though the patient

has been undergoing periodontal therapy.

35

BJM Vol. 21 No. 1 Oral Hygiene Among Type 2 Diabetes Patients: A Study of 276 Cases

Diabetes increases susceptibility to periodontitis

• Advanced glycation end products deposited in the

tissues as a result of hyperglycaemia can alter

the phenotype of macrophages and other cells via

a specific cell-surface receptor. Macrophages are

key cells in the pathogenesis of periodontitis

through their ability to produce a large array of

cytokines. They also influence the inflammatory

response, the metabolism of fibroblasts and

lymphocytes and stimulate bone resorption via

prostaglandin E2. It is thought that the advanced

glycation end products transform the macrophages

into cells with a destructive phenotype, producing

pro-inflammatory cytokines in an uncontrolled

fashion.

• Neutrophils are the primary defence cells of the

periodontium. The reduced neutrophil function

observed in patients with diabetes is therefore

another mechanism increasing the susceptibility

to periodontitis.

Relationship between periodontitis and the ability

to control diabetes?

While periodontitis is a recognised complication of

poorly controlled diabetes, it has been proposed that

severe periodontitis may make the metabolic control

of diabetes more difficult. The process may be

mediated through the systemic release of

inflammatory cytokines (e.g. TNF-á) from periodontitis

lesions, and chronic low-level systemic exposure to

Gram negative organisms. periodontitis may

contribute to elevated proinflammatory cytokines/

serum lipids and potentially to systemic disease

arising from chronic hyperlipidemia and/or increased

inflammatory mediators. These cytokines can produce

an insulin resistance syndrome similar to that

observed in diabetes and initiate destruction of

pancreatic beta cells leading to development of

diabetes. Thus, there is potential for periodontitis to

exacerbate diabetes-induced hyperlipidemia, immune

cell alterations and diminished tissue repair capacity.

What can the patient do?

• People with diabetes need to practise high

standards of daily oral hygiene, including

brushing and flossing.

• Adjunctive use of a chlorhexidine mouthwash

(0.12%) or chlorhexidine gel (0.2%) twice daily

(used independently of toothpaste so that the

chlorhexidine is not inactivated) may be useful

in controlling the more severe disease.

• Medical practitioners who suspect a patient has

diabetes-related gingivitis or periodontitis should

ensure that an early referral is made to a dentist.

Dentists in turn need to refer advanced or suspect

cases to a periodontist.

Therefore, Medical and dental practitioners need to

be aware of the interrelationship between poorly

controlled or undiagnosed diabetes mellitus and

chronic gingivitis and periodontitis. This is

particularly important because of the rising

prevalence of diabetes in the community.

References

1. Soskolne WA, Klinger A. The relationship between

periodontal diseases and diabetes: an overview. Ann

Periodontol 2001; 6: 91-8.

2. Bjelland S, Bray P, Gupta N, Hirscht R. Dentists,

diabetes and periodontitis. Aust Dent J 2002; 47:

202-7.

3. Mealy B. Position paper. Diabetes and periodontal

diseases. J Periodontol 2000; 71: 664-78. http://

www.per io .o rg/resources -products/pd f/ l r -

diabetes.pdf [cited 2004 March]

4. Grossi SG, Genco RJ. Periodontal disease and

diabetes mellitus: a two-way relationship. Ann

Periodontol 1998; 3: 51-61.

5. Papapanou PN. Periodontal disease: epidemiology.

Ann Periodontol. 1996; 1: 1-36.

6. Hugoson A, Thorstensson H, Falk H, Kuylenstierna

J. Periodontal conditions in insulin-dependent

diabetics. J Clin Periodontol 1989; 16: 215-223.

7. Thorstensson H, Hugoson A. Periodontal disease

experience in adult long-duration insulin-dependent

diabetics. J Clin Periodontol 1993; 20: 352-358.

Fig.-2: The lower left lateral incisor (*) is very mobile

and has migrated from its usual location in the arch. The

tooth has lost more than two-thirds of its supporting bone

because of periodontitis and abscess formation.

36

Oral Hygiene Among Type 2 Diabetes Patients: A Study of 276 Cases BJM Vol. 21 No. 1

Introduction:

Women mental health is an important issue now

days. The World Health Organization (WHO)

observed women mental health as their theme of

World Mental Health Day in 1996. Mental health is

not a priority and women mental health is much

neglected in Bangladesh. Majority of the people of

Bangladesh are living in the rural areas where

psychiatric services are not available. In these areas

people are not aware of the scientific management

of psychiatric problem rather these patients are

thought to have possessed by spirit or deity. In a

study it was found that even people near Mitford

Hospital in old Dhaka city were not still aware of

the availability of psychiatric services in that hospital1. Lack of awareness about the illness and proper

training of the physicians, low education, poor socio-

economic status, prevailing superstitious and stigma

of mental illness may be the strong reasons of these

beliefs.

1. Associate Professor, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU),

Shahbagh, Dhaka, Bangladesh.

2. Assistant Professor, Department of Psychiatry, BSMMU, Shahbagh, Dhaka, Bangladesh.

3. Medical Officer, Department of Psychiatry, BSMMU, Shahbagh, Dhaka, Bangladesh.

4. Research Assistant, Department of Psychiatry, BSMMU, Shahbagh, Dhaka, Bangladesh.

PSYCHIATRIC MORBIDITY AMONG WOMEN WHOSE

HUSBANDS ARE LIVING ABROAD

M A SALAM1, MOHAMMAD S. AHSAN2, NAFIA F. CHOWDHURY3. SYED F. SHAMS3, NAHID M. MORSHED1,

MOHSIN ALI SHAH1, MONIRUL ISLAM4

Abstract:

Introduction: A large number of people working aboard leave their wives home in rural areas of

Bangladesh. Husbands living abroad apart from their wives, play a significant role on the mental

health status of these married women. This study was carried out to see the Psychiatric morbidity

among those women whose husbands were living in aboard. Methods: This is a cross-sectional

study. A total number of 960 female patients came for psychiatric consultation in the out-patient

department of a private hospital from January 2008 to December 2009. Among them, 150 patients

were included in this study whose husbands were living abroad. Diagnoses were made as per

criteria of Diagnosis and Statistical Manual for Mental and Behavioral Disorder (DSM-IV). Results:

Majority of the patients (76.52%) were in 15-30 years of age group and most of the female were

house wives. Regarding socio-economic status 61.73% were lower middle and 13.04% were low

socio economic condition respectively. It was found that 51.30% of the patients were major depressive

disorder, 27.83% were somatoform disorder (0f which 13.04% had conversion disorder and 12.17%

had psychogenic headache), 06.08% were schizophrenic, 06.95% had bipolar disorder and 04.35%

had anxiety disorders. Conclusion: This study reveals significant number of women suffering from

psychiatric illness in rural areas. More emphasis should be given in psychiatric health care services

in primary health care level in Bangladesh.

Key words: Women mental health, Primary health care.

Recently several studies have reported worldwide

higher prevalence of some mental illness among the

women population. In an epidemiological study on

mental illness in Bangladesh, the prevalence of

psychiatric illness was found to be 16.1% and

depression was found to be 6.40% 2. In last few

decades there is an uprising trend of migration of

workers from rural and urban areas from the different

regions of Bangladesh. Majority of the workers are

unskilled and migrate mostly to Middle-East

countries. Most of the migrants are from low and

lower-middle income groups. They leave behind their

wives at home in villages of Bangladesh as wages

are very low. They stay on average for a period of 3-

5 years in abroad, keeping their wives and other

family members in the villages. From a study it was

found that the lack of some one to confide in acts

as a vulnerable factor for development of depression

in women in rural areas3.

Bangladesh J Medicine 2010; 21 : 37-40

The wives of the persons who migrated abroad for

jobs are the population of the present study. This

group of people dwells in poverty has poor education,

early marriage, adjustment problem and has lack of

social support. So, psychiatric assessment of these

women was done to see the psychiatric illness. This

study was carried out at a district level private

hospital in Comilla district, which is situated in the

eastern part of Bangladesh, 100 kilometer away from

Capital city Dhaka. This town lies in the adjacent

areas of Dhaka-Chittagong Highway and Dhaka-

Chittagong inter-district train has a stopover in this

town. The trend among many physicians in

Bangladesh is as such that specialist doctors on

weekly holidays (Friday) visits to the different areas

of other districts from major city especially from Dhaka

to deliver service. The patients also come to the town

on weekly holiday to take the specialists’ service.

Good communication network drags people from the

adjacent areas to come to and take the opportunity

of seeking medical help from the town. So, a good

number of patients come to seek specialist service

at weekend.

Methods:

This is a cross-sectional study. A total number of

960 new female patients came for psychiatric

consultations for the the first time to the out-patient

department of a private hospital from January 2008

to December 2009. Data were collected from the

registrar book of the patient. Out of 960 female

patients, 115 female patients were included in this

study whose husbands went abroad for job. These

patients were interviewed by a qualified psychiatrist

and psychiatric diagnoses were made as per criteria

of Diagnosis and Statistical Manual for Mental and

Behavioral Disorder (DSM-IV). The collected data were

cleaned, sorted and analyzed and the results were

presented in tables and figures.

Results:

Table. I showed that the majority of the patients

(76.52%) were in 15-30 years of age group followed

by 31-40 year (18.26%) of age group. Regarding

occupation most of the female were house wives

(95.65%). About 90.43% of the female are living the

rural areas. In Table II it was found that 47.82%

have primary education and 22.60% are illiterate.

Regarding socio-economic status 61.73% are lower

middle and 13.04% are low socio economic condition

respectively.

Table- I

Age distribution of the subjects (n= 115)

Age in years Number &

Percentage (%)

15-30 88 (76.52%)

31-40 21(18.26%)

41-50 06(5.22%)

50+ 00 (0%)

Table- II

Other sample characteristics of the subjects (n=115)

Sample characteristics No (%)

Residence Urban 11 (9.57%)

Rural 104(90.43%)

Occupation Housewife 110(95.65%)

Service 05(4.35%)

Others 00(0%)

Education Illiterate 26(22.60%)

Primary 55(47.82%)

Secondary 33(28.70%)

Higher 01(0.87%)

In Table III, it was found that 51.30% of the patients

were Major Depressive Disorder and 27.83% were

Somatoform Disorder (of which 13.04% had

Conversion Disorder and 12.17% had Psychogenic

Headache), 06.08% were Schizophrenic, 06.95% had

Bipolar Mood Disorder and 04.35% had Anxiety

Disorders.

Fig-1: Distribution of socio economic status of the

subjects

38

Psychiatric Morbidity among Women Whose Husbands are Living Abroad BJM Vol. 21 No. 1

Discussion:

The aim of this study was to find out the psychiatric

morbidity among female patients whose husbands

are doing jobs in abroad. Service delivery model of

mental health care in the low income countries like

in Bangladesh is to provide most of the formal mental

health care in primary mental health care settings

as suggested by the World Health Organization

(WHO). Consultations for complex cases and

inpatients can be managed in primary care center 4.

In many settings informal care is provided by the

families, other community resources and care by

traditional healers may assure central importance 5.

In Bangladesh, the first mental hospital was

established in Pabna, north to the capital of

Bangladesh as Mental Hospital Pabna. Besides, most

of the government medical colleges in Bangladesh

are situated in urban cities and have their psychiatric

departments with either outpatient or both out and

inpatient facilities. Mental health care is not

incorporated in the primary care setting in

Bangladesh. So majority of Bangladeshi who are

residing in rural areas that need specialist mental

health services are inaccessible to the government

mental health facilities. With this existing reality in

this country, an alternate service model is growing

up. That is, the specialists residing in urban areas

come to the upazilla (previously known as thana) and

district town to deliver specialist mental health

service in weekly holidays (Friday).Thereby, providing

some form of mental health care in the primary care

level.

In present study, the highest numbers of psychiatric

patients were in age group 15-30 years (76.52%), which

was consistent with other studies like, in a study

done to see the diagnostic criteria group attending in

satellite consultation services in rural area and it

was seen that 30.57 % of the females were of 21-30

year age 6. Regarding psychiatric morbidity it was

observed that about 58.26% of the patients were

suffering from the Mood Disorder. Of them 51.30 %(

59) were suffering from Major Depressive Disorder.

Researchers have found in a study that depression

was twice as common as in men. The reasons for the

difference have been hypothesized to involve hormonal

differences, the effects of child birth, differing

psychosocial stressors for women 3. Another study

done in Bangladesh showed that 51.59 % were

suffering from Mood Disorder, 16.18 % were suffering

from Anxiety Disorder, 12.66 % Somatoform Disorder,

12.14 % were Schizophrenia which was very much

close to this study 7 .

The reason for the high percentage of depression

among women in Bangladesh can be explained in

many ways. Women in rural areas in Bangladesh have

to take a major role in household activities. In

addition they marry early, have to take of more than

Table- III

Distribution of psychiatric illness among the subjects (n=115)

Types Subtypes Frequency Percentage

Schizophrenia and other Schizophrenia 2 07 6.09%

psychotic disorders Delusional disorder 1

Brief psychotic disorder 4

Mood disorders Major depressive disorder 59(51.30%) 67 58.26%

Bipolar disorder 8(06.95 %)

Anxiety disorders Generalized anxiety disorder 1 05 4.35%

Panic disorder 1

Specific and Social phobia 1

Obsessive compulsive disorder 2

Somatoform disorders Conversion disorder 15(13.04%) 32 27.83%

Somatoform disorder NOS 3

Psychogenic headache 14(12.17 %)

Adjustment disorder 2 02 1.74%

Organic disorder Migraine

Seizure disorder 11 02 1.74%

39

BJM Vol. 21 No. 1 Psychiatric Morbidity among Women Whose Husbands are Living Abroad

2 to 3 children at home. They are the victim of many

maladjustment problems. High level of uneducated

women is also assumed to be associated with low

skill as well as poor coping mechanism. These factors

altogether perhaps play role in precipitating psychiatric

problems 3.

In Bangladeshi culture women are less rewarded for

their contribution in spite of their hard work and

contribution in the families. In this study the

husbands of the respondents were staying abroad

and used to come back home very seldom. Moreover,

having care of children 03 or more age below 14 is

vulnerable for depression. This could be a major factor

for the high rate of depression among the

respondents. Deprivation of mental support from the

spouse and deprivation of physical needs may play a

major role in causation of depression. It was also

observed that about 27.83% of the respondents were

suffering from Somatoform disorder. It included

conversion disorder 13.04% and psychogenic

headache 12.17%. Majority of the patients were of

age 15-30 years. This age group is very significant in

our cultural background. Early marriage, conflict in

social circumstances, social stigma all contribute to

produce physical symptoms of above diseases.

Schizophrenia and Bipolar Mood Disorder were

06.09%, and 06.96% respectively. Adjustment disorder

was 1.74% and Anxiety disorder 4.35%.

Conclusions:

This study showed that psychiatric morbidity among

the female patients is very considerable. It is a global

problem including Bangladesh. We know that

majority of the female psychiatric patients do not come

to the psychiatrists or hospital for treatment.

However this significant proportion of female

psychiatric patients indicates that there is an urgent

need to provide psychiatric services in all district level

hospital in Bangladesh.

References:

1. Rahim DA, Banu NM, Islam H. Female psychiatric

morbidity in out patient of Mitford Hospital.

Bangladesh J Psychiatry 1997; 11: 17-20.

2. Firoz AHM, Karim ME, Alam MF, Rahman AHMM,

Zaman MM. Prevalence, Medical Care, Awareness

and Attitude Towards Mental Illness in Bangladesh.

Bangadesh J Psychiatry 2006; 20(1): 9-36.

3. Ara N, Hossain GM, Islam MT. Women mental health

in rural part of Bangladesh. Bangladesh J Psychiatry

2001; 15: 5-10.

4. Mubbashar M. Mental health services in rural

Pakistan. In M. Tansellaand G. Thornicroft (eds).

Common Mental Disorders in Primary Care. London:

Routledge; 1999: 67-8.

5. Desjarlais R, Eisenberg L, Good B. World Mental

Health. Problems and priorities in law income

countries 1995; Oxford: Oxford University Press.

6. Alam F, Hamid A, Ahmad S, Ahsan MN, Diagnoses

of patients: An Observation in Psychiatric

Consultation services in rural Bangladesh,

Bangladesh Journal of Psychiatry 2000; 14:6-9.

7. Hamid A, Choudhury S, Nizamuddin M, Mohit MA,

Comparative study of patients in different outpatient

departments (OPDS) and pattern of Psychiatric

disorders in a district Hospital, Bangladesh Journal

of Psychiatry 2003;17:5-13.

40

Psychiatric Morbidity among Women Whose Husbands are Living Abroad BJM Vol. 21 No. 1

Introduction

Infectious complications after renal transplantation

(RT) may lead to prolonged hospitalization, sepsis,

and death 1,2. The majority of infections appear to be

due to gram-negative bacteria associated with urinary

tract infection or deep wound infection 3,4. Fungal

and other opportunistic infections may also occur 2,5,6.

Despite the propensity for infection in these patients,

reports of septic arthritis have been uncommon. We

report a case of septic arthritis in a renal transplant

recipient on immunosuppressive therapy who

responded well after prolong parenteral antibiotic

therapy.

Case Report

A 35-year-old man with a history of chronic

glomerulonephritis and resultant End-stage renal

disease had a renal transplant from a live related

donar in April, 2009. Prior to transplantation he was

on MHD for 5 months. He had an uncomplicated

postoperative course. Immunosuppressive treatment

included prednisolone, cyclosporine and

mycophenolate mofetil.

The patient did well until late September 2009, when

he began to experience. Continued fever along with

rigors, malaise, myalgia and night sweats that

responded little to antipyretics. A dry cough began 10

SEPTIC ARTHRITIS IN A RENAL TRANSPLANT

PATIENT

PRADIP KUMAR DUTTA1, SAYED MD JABED2, SAIBAL DAS3, MD NURUL HUDA3, MD MAMINUL ISLAM4 ,

DIPEN CHOWDHURY4,MD SHARIFUL ISLAM4, ABUL KASHEM1, DIPTI CHOWDHURY5

Abstract

Infectious complications in the renal transplant patient are common but the incidence of septic

arthritis in transplant patient is less documented. The knee was most commonly infected joint. We

report a case of monoarticular septic arthritis in a renal transplantation recipient. The ankle joint

was involved in our case. Septic arthritis may be missed as other rheumatological disorders may

mimic in transplant patient. If proper attention is not given to locomotor system it may not be

diagnosed early. Besides as pt is on immunosuppressive therapy prolonged antibiotic therapy is

warranted. Prompt and prolonged antibiotic therapy resulted in quick resolution of the joint infection

in our patient. Impaired host defenses, possible inadequate and delayed prior antibiotic therapy,

and intrinsic joint alterations are potential contributing factors to the development of septic arthritis

following renal transplantation. So in spite of the low frequency of occurrence of septic arthritis,

persistent attention to the locomotor system in the transplant patient is warranted.

1. Associate Professor of Nephrology, Chittagong Medical College

2. Honorary Medical Officer. Nephrology, Chittagong Medical College

3. Assistant Professor of Nephrology, Chittagong Medical College

4. MD (Nephrology) Thesis part student, Chittagong Medical College

5. Professor of Nephrology, Chittagong Medical College

days later which became productive with purulent

sputum with occasional haemoptysis within the next

week. The scenario was further complicated by

development of pain and swelling in the right ankle

joint without any history of trauma 10 days prior to

admission. Bowel and bladder habit was normal

throughout the course. He was non diabetic with no

previous history of tuberculosis, joint symptoms or

recent skin infection. Treatment with several oral

antibiotics failed to control symptoms. His

immunosuppressive therapy consisted of prednisone

15mg, cyclosporine 175 mg and mycophenolate mofetil

1 g daily. When the patient was admitted to our

institution for evaluation and treatment on 1st October

2009, he was found ill-looking and distressed with

frequent purulent cough. His pulse was 130/min, BP-

100/70mm (Hg), temp-1030F and Respiratory rate-25/

min, mildly anaemic with normal JVP. Chest

examination revealed creps on the left upper area.

Red, hot, swelled right ankle had Grade-III tenderness

with limited active and passive movements.

Otherwise, the results of his examination were

normal, and his transplanted kidney was not tender.

Initial investigation showed Hb-10.1g/dl with WBC-

25000/cm3, CXR showed left upper zone

consolidation.

Bangladesh J Medicine 2010; 21 : 53-54

In view of the above clinical and laboratory data, the

patient was diagnosed as a case of pneumonia and

septic arthritis and empirical parenteral antibiotic

treatment commenced with Inj.Meropenem,

inj.Flucloxacillin, inj.Metronidazole without stopping

immunosuppessive treatments. Cough disappeared

within 7 days with resolution of creps but intermittent

fever persisted along with joint symptoms till 20th

day of treatment and then gradually settled down.

Patient became symptom free from 25th day onwards.

Parenteral antibiotics were continued for 28 days.

Follow up investigations revealed resolution of

consolidation while CBC revealed WBC-12600/cm3

on 20th day of treatment. He was discharged on 3rd

December.

Discussion:

Bacterial, fungal, mycobacterium, and viral infections

have been well documented in RT patients 2,3,6,7,8.

Bacteria are the major cause of infections, which

usually occur in the urinary tract, although

septicemia, skin, and wound infections are common1,3,4 .Recent series from different institutions, 50

(29%) of 174 and 164 (32%) of 518 RT patients

developed infections 4,6.

In contrast, despite the high frequency of these other

infections, the incidence of septic arthritis appears

quite low. In one series, bomalaski et al reported only

6 of 800 transplanted patients developed septic

arthritis. and in 11 reported studies of RT patients

covering the period from 1964 through 1980, only 1

case of septic arthritis in 1,033 patients was reported4,5,7. E coli, Enterococcus, S marcescens, P

aeruginosa, M tuberculosis and atypical mycobacterial

organisms are common bacterial etiology7. Fungus

Cryptococcus and CMV were reported 2,8,9. In all

series, knee was the most common site of infection.

Synovial fluids commonly showed WBC within 40000-

70000/cm3 with PMN predominance and raised

peripheral WBC count 7,8,10,14. Most responded to

antimicrobials and aspirations, open drainage and

arthrotomy were required in some cases mainly in

mycobacterial etiology.7,11,12,13

Our patient had ankle arthritis which was not

commonly found in other studies 7,9,11,14 .But he

presented 6 month post transplant which was close

to the median time of presentation (5.5 months) and

also had immunosuppressive therapy and concomitant

chest infection as predisposing agents. High

peripheral WBC counts further supported the

diagnosis and respond to antibiotics suggested

bacterial infection though organisms could not be

identified. Joint and systemic symptoms

concomitantly disappeared along with normalization

of WBC count and relapses not occurred yet.

Conclusion:

Infections are common in RT patients; however,

infectious arthritis occurs infrequently. Reinfection

or relapsing infection may occur despite an apparently

adequate regimen of antibiotic therapy. If not treated

early, it may lead to open drainage, arthrotomy and

amputation. But early diagnosis and proper

antimicrobial therapy can alone effective as in our

patient. Immunosuppressives need not to withdraw

to clear the infection.

References:

1. Ramos E, Karmi S, Alonzi SV, Dagher FJ: Infectious

coinplications in renal transplant recipients. South

Med J 1980; 73:751-754.

2. Biaf ZF, Altmann G, Ostfield E: Fungal infections

after renal transplantation. Isr J Med Sci 1976;

12:674-677.

3. Eickhoff TC: Infectious complications in renal

transplant recipients. Transplant Proc 1973;

3:1233-1238.

4. Lobo PI, Rudolf LE, Krieger JN: Wound infections

in renal transplant recipients-a complication of

urinary tract infections during allograft malfunction.

Surgery 1982; 92:491-496.

5. Myerowitz RL, Medeiros AA, O’Brien TF: Bacterial

infection in renal homotransplant recipients: a study

of fifty-three bacteremic episodes. Am J Med 1972;

53:30.

6. Peterson PK, Ferguson R, Fryd DS, Balfour

HH,Rynasiewicz J, Simmons RL: Infectious diseases

in hospitalized renal transplant recipients: a

prospective study of a complex and evolving problem.

Medicine (Baltimore) 1982; 61:360-372.

7. Bomalasky JS, Williamson PK, Goldstein CS:

Infectious Arthritis in renal transplant

patient.Arthritis & Rheumatism 1986; 29:227–232.

8. Friedman HM, Pincus T, Gibilisco P, Baker D,

Glazer JP, Plotkin SA, Schumacher HR Jr: Acute

monoarticular arthritis caused by herpes simplex

virus and cytomegalovirus. Am J Med 1980; 69:241-

247.

9. Lefl RD, Smith EJ, Aldo-Benson MA, Aronoff

GR:Cryptococcal arthritis after renal

transplantation. South Med J 1981;74: 1290.

10. Irby R, Edwards WM, Gatter R: Articular

complications of homotransplantation and chronic

renal hemodialysis.J Rheumatol 1975;2: 91-99.

11. Ascher HL, Simmons RL, Marker S, Klugman

J,Najarion JS: Tuberculous joint disease in

transplant patients. Am J Surg 1978; 135:853-856

12. Bomalaski JS: Rheumatologic manifestations of

atypical mycobacteria (abstract). Arthritis Rheum

(suppl) 1983;26: S48.

13. Hall MC, Elmore SM, Bright RW, Pierce JC, Hume

DM: Skeletal complications in a series of human

renal allografts. JAMA 1969; 208: 1825-1829.

14. Vincenti F, Amend WJ, Feduska NJ, Salvatierra 0:

Septic arthritis following renal transplantation.

Nephron 1982; 30:253-256.

54

Septic Arthritis in a Renal Transplant Patient BJM Vol. 21 No. 1

Introduction

Vitiligo is an acquired pigmentary anomaly of the skin,

manifested by depigmented white patches surrounded

by a normal or a hyperpigmented border. Vitiligo

usually begins in childhood or young adulthood;

approximately one half of those with vitiligo acquire

the disease before the age of 20 years, and the

incidence decreases with increasing age. The

prevalence of the disease ranges from 0.5% to 1%.

All races and both sexes are equally affected 1.

Histologically melanocytes are completely absent in

the vitiliginous patches and usually there is no

inflammatory component1. Recently, research at the

molecular level has demonstrated deficiency of

antioxidant substances in vitiliginous skin. This leads

to cytotoxic action of reactive oxygen species such

as, super oxide anion and hydroxyl radical which are

generated by the ultraviolet damaged epidermis. The

free radicals are also cytotoxic to melanocytes and

inhibit tyrosinase 2.

SERUM ZINC LEVEL IN PATIENTS WITH VITILIGO IN

A TERTIARY HOSPITAL IN BANGLADESH

RUBAIYA ALI1, NARGIS AKHTAR 2, MOHAMMAD S. AHSAN3, AYESHA HASSAN4, MOHAMMAD ASIFUZZAMAN5

Abstract

Background: Vitiligo is a common and chronic skin disease in dermatological practice. It is found that

there is deficiency of anti-oxidant substances in vitiliginous skin. Zinc is considered as an anti

oxidant and also plays an important role in the process of melanogenesis. So far, studies have

shown a variation in zinc level in patients with vitiligo. Objective: The present study was done to

see the serum zinc level in patients with vitiligo. Methods: Total 30 patients with vitiligo were

purposively taken from the department of Dermatology and Venereology of Bangabandhu Sheikh

Mujib Medical University (BSMMU) and 30 healthy controls were taken and zinc level was estimated

in both groups. The duration of the study was six months from 1st September 2007 to 29th February

2008. Results: The study result showed that mean zinc level of vitiligo patients were 1.06 ± 0.08

and that of controls were 0.91± 0.33. Mean zinc level in both groups was found within normal

reference range. However, In vitiligo patients mean zinc level was observed higher than that of

controls. This difference was found statistically significant (p<0.05). Conclusion: In this study

serum zinc level in patients with vitiligo was found within normal range and higher than that of

control. However, further studies with larger sample size may give a more significant relation of

serum zinc and vitiligo.

Key words: Vitiligo, serum zinc.

1. Assistant Professor, Department of Dermatology and Venereology, Ad-Din Medical College and Hospital,

Dhaka.

2. Associate Professor, Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical

University (BSMMU), Dhaka.

3. Assistant Professor, Department of Psychiatry, BSMMU, Shahbagh, Dhaka..

4. Assistant Professor, Department of Dermatology and Venereology, Delta Medical College and Hospital,

Mirpur, Dhaka.

5. Assistant Professor, Department of Dermatology and Venereology, ZH Sikder Women’s Medical College

and Hospital.

Zinc is a trace element and its essentiality is related

mainly to its function as the metal moiety of the

important enzymes. Zinc is considered as an

antioxidant because the extracellular enzyme

superoxide dismutase is zinc dependent. Superoxide

dismutase is a group of metalloenzymes that protect

cells from the toxic effects of super oxide radicals3.Zinc also plays an important role in the process of

melanogenesis4. Thus zinc has a significant role in

the pathogenesis of vitiligo. In India Shameer et al5

found some interesting correlations between low zinc

levels and vitiligo. Similar finding was observed in

Germany 6. But Helmy et al7 found that serum Zinc

and copper levels were significantly higher in active

vitiligo patients than controls. So, there is variation

of serum zinc level among patients with vitiligo.

However, no such studies were carried out in

Bangladesh.

Bangladesh J Medicine 2010; 21 : 14-18

Methods

This was a case control study. Sampling technique

was purposive. Sample size (n) was 60 (30 case, 30

control). This study was conducted in the

Department of Dermatology and Venereology,

BSMMU, Shahbagh, Dhaka, Bangladesh. The study

period was of six months (1st September 2007 to

29th February 2008). Patients of vitiligo of any age

and both sexes were selected as cases. As controls,

age and sex matched healthy individual who were

not on any form of zinc medication were included.

However, patients having leukoderma secondary to

other causes, or history of suffering from other

obvious skin diseases, or undergoing treatment

with Zn or any history of zinc intake for 04 months

prior to this study, or suffering from any other

systemic diseases such as, cirrhosis of liver, viral

hepatitis, neoplastic condition, myocardial

infarction, steatorrhoea and renal failure were

excluded from the study. Patients who were

pregnant or consuming oral contraceptive pills were

also excluded.

Patients were diagnosed clinically and Wood’s lamp

examination was carried out to confirm it. Informed

written consent was taken from every one. A

questionnaire consisting of particulars of the

participants, socio-demographic data, clinical data

and laboratory findings was used. 5 ml of venous

blood was collected from both case and control

group in special sterile tubes and was centrifuged

for 15 minutes at 2000 rpm (Rotations per minute).

The supernatant serum was transferred to a

separate sterile tube (Appendorf tube) and kept at

-20 0 C in the deep freezer till the analysis. The

serum zinc level was measured by ‘Atomic

absorption spectrophotometry (AAS) [Flame

method] at Centre for Advanced Research in

Physical Chemical, Biological and Pharmaceuticals

Sciences, University of Dhaka.Data was checked

for inadequacy, irrelevancy, and inconsistency.

Irrelevant data were discarded. For the statistical

analysis, one Microsoft Windows- based software

package was used (SPSS 13 for Windows, SPPS

Incorporation, Chicago, IL, USA). Data process on

categorical scale was presented as frequency and

percentage and was analyzed by c2 tests. While

the data present on continuous scale was

presented as mean and SD and analyzed with the

help of Student ‘t’ test (Unpaired). Statistical

significance is set at 0.05 level and confidence

interval at 95% level.

Results

The mean age of the case group patients was 30.27

years with a standard deviation of ±11.09 and that in

controls 32.27 years with a standard deviation of

±11.08. As it was an age and sex matched study, so

distribution of respondents within different age

ranges were kept in equal number (Table-I).

Table-I

Distribution of the respondents by mean age and

standard deviation of both groups (n = 60)

Age (year) Group P value*

Case Control

11-20 18.00±1.73§ 19.40±.89 0.147

21-30 26.07±3.31 27.31±2.06 0.259

31-40 37.50±2.08 35.17±3.31 0.250

41-50 46.25±1.5 47.50±3.79 0.562

51-60 51.00±.0 57.50±3.54 0.122

Total 30.27±11.09 32.27±11.08 0.555

§ Mean ± Standard deviation

* Unpaired t test was used to measure the level of

significance. p value <.05 was considered as a level of

significance

Most of the participants were in the age group of 21-

30 (50%) (Table-II).

No significant difference was observed between groups

in term of frequency distribution of respondents in

different age groups (p>0.05) (Table-II).

Table II

Distribution of the respondents by frequency of age of

both groups (n = 60)

Age (year) Group p value*

Case Control

11-20 5 (16.7)# 5 (16.7)

21-30 15 (50.0) 15 (50.0)

31-40 4 (13.3) 4 (13.3) 0.969

41-50 4 (13.3) 4 (13.3)

51-60 2 (6.7) 2 (6.7)

Total 30 (100.0) 30 (100.0)

# Figure within parenthesis denoted corresponding

percentage.

* Chi square test was used to measure the level of

significance. p value <0.05 was considered as a level of

significance

15

BJM Vol. 21 No. 1 Serum Zinc level in patients with Vitiligo in a Tertiary Hospital in Bangladesh

Female respondents outnumbered their male

counterpart and male and female ratio is 1:1.7.

25 (83.3%) among the cases were nonsmoker, 04

(13.3%) smoker and 01 (3.3%) ex-smoker. However

among controls the numbers were 23 (76.7%), 5

(16.7%) and 2 (6.7%) respectively. No statistical

significance difference was found in term of smoking

habit of both groups (p>0.05).

Table III

Features of vitiligo patients (n=30)

Frequency Percent

Distribution

• Symmetrical 14 46.7

• Asymmetrical 16 53.3

Morphological pattern

• Localized or focal 18 60.0

• Acrofacial 5 16.7

• Generalized 7 23.3

Koebner sign 10 33.3

Itching over patches 7 23.3

Scaling 3 10.0

Table IV

Distribution of the respondents of both case and control

group by serum Zn level (n=60)

Zinc level Mean±SD (mg/L) p value*

Case 1.06±0.08 0.014

Control 0.91±0.33

* Unpaired‘t’ test was done to measure the level of

significance.

Only 04 (13.4%) patients had positive family history

of vitiligo (Fig-I).

Fifteen (50%) patients had 1-5 depigmented patches

and 08 (26.7%) patients had 6-10 patches, 04 (13.3%)

had 11-15 numbers of patches and 03 (10%) patients

had 16-20 no of patches. (Fig-III).

Fig.-I: Family history of Vitiligo among the case group (n=30)

Twenty one patients (70%) had been suffering for 1-

5 months; whereas, 07 (23.4%) patients for 6-10

months, patients (3.3%) for 11-15 months and one

patient (3.3%) had illness for 16-20 months of illness

(Fig-II).

Fig.-II : Duration of illness of the patients (n=30)

Fig.-III: Depigmented white patches of the patients

14(46.7%) patients had symmetrical distribution of

vitiligo patches and 53.3% had asymmetrical

distribution. Localized or focal pattern vitiligo was

observed more. Eighteen (60%) patients had localized

or focal pattern vitiligo followed by 7 (23.3%)

generalized pattern and 5 (16.7%) had acrofacial

pattern. Ten (33.3%) patients had koebner sign, 7

(23.3%) patients had itching over patches and 3

(10.0%) patients had scaling (Table-III).

Mean zinc levels of both case and control groups were

within normal reference level. In vitiligo patients mean

zinc level was observed higher than that of control

group. Mean serum zinc level in case group was

1.06±0.08 and in control group was 0.91±0.33. This

16

Serum Zinc level in patients with Vitiligo in a Tertiary Hospital in Bangladesh BJM Vol. 21 No. 1

difference was found statistically significant

(Table-IV).

Discussion

Zinc is categorized as a trace element as it

constitutes less than 0.005% of total body weight.

Normal serum zinc level ranges from 0.7-1.6 mg/L 8.

No statistically significant difference in mean values

of serum zinc levels was observed in relation to sex,

age, race, food habits and diurnal variation. Zinc is

an integral part of as many as 40 metalloenzymes. It

takes part in virtually all body functions from

spermatogenesis to growth to abstract thought

processes. Zinc deficiency characteristically causes

the cutaneous disorder of acrodermatitis

enteropathica manifestating as acral and periorificial

skin eruptions, alopecia, diarrhoea and growth

retardation. Some zinc investigators have also

reported low serum zinc levels in cutaneous leg ulcers

etc, while others have not found the same. Some

authors have found abnormalities of serum zinc level

in cutaneous disorders like psoriasis and lichen

planus9. In our study zinc level was found significantly

higher in vitiligo patients than controls. This finding

was not agreed with the finding of Shameer et al 5

(Zinc level was found reduced in 13of 60 patients -

26.6%).But Helmy et al7 aimed in his study to evaluate

whether the activity of the disease was associated

with a systemic oxidative stress manifested as

apoptosis of Peripheral Blood Mononuclear Cells

(PBMC) and also aimed to evaluate the role of Zinc

and copper in the pathogenesis of vitiligo. They found

that serum Zinc and copper levels were significantly

higher in active vitiligo patients than controls due to

higher percentage of apoptotic PBMCs in active vitiligo

with increased release of zinc and copper in serum.

Their results also confirmed that a systemic oxidative

stress had a role in active vitiligo leading to

melanocyte degeneration.

Serum zinc levels were studied in 75 patients of

different cutaneous disorders and 24 healthy controls

by Arora et al9. No significant correlation was found

in the cutaneous disorders studied i.e. vitiligo and

aphthous ulcers where serum zinc levels were found

to be 97.3 ±26.6 ì gm/100 ml and 105.2 ± 23.5 ìgm/

100 ml respectively.

In this study, mean age of the case group patients

was 30.27 years with a standard deviation of ±11.09

and in control group 32.27 years with a standard

deviation of ±11.08. As it was an age and sex matched

study, so distribution of respondents within different

age ranges were kept in equal number. Maximum

respondents of the case and control groups were

within 21-30 years age range (50.0 vs. 50.0) followed

by 11-20 years (16.7 vs. 16.7). This result was

comparable with Shameer et al 5. Mean age of their

respondents was 33.8 years. Male and female ratio

of their series was 4.5:1. But in our series it was

1:1.7.

Within case group only 04 (3.4%) patients had positive

family history of vitiligo. In Shameer et al 5series

33% of the patients had positive family history of

vitiligo.

Mean duration of suffering from vitiligo was 5.0

months with a standard deviation of ±3.79 months.

Maximum patients (70.0%) had been suffering from

vitiligo for 1 to 5 months.

Mean duration of suffering from vitiligo was 2 years

in Shameer et al series5.

Conclusion

In some earlier studies variable degree of correlation

between serum zinc

level and vitiligo were observed. In a recent study

conducted in India has shown low level of serum zinc

is a significant risk factor for vitiligo 4. But this study

on the contrary showed significant higher level of

serum zinc in vitiligo patients than that of controls.

Limitations of the study

• Sample number was small.

• Period of study was short.

• Confounders were not addressed.

• As purposive sampling was done, findings were

not free from biasness.

Recommendation

• Study with longer duration should be carried out

with larger sample size.

• Multicenter study should be carried out to reveal

accurate pattern of zinc status in vitiligo.

References:

1. Odom RB, James WD, Berger TG, (eds). Andrews’.

Diseases of the Skin. Clinical dermatology, 10th ed.

W.B. Saunders Company, Philadelphia. pp. 860-3.

2. Schallreuter KU, Wood JM, Berger J. Low catalase

levels in the epidermis of patients with vitiligo.

Invest Dermatol 1991; 97:1081-5.

17

BJM Vol. 21 No. 1 Serum Zinc level in patients with Vitiligo in a Tertiary Hospital in Bangladesh

3. Yildirim M, Baysal V, Inaloz HS, Can MM. The role

of oxidants and antioxidants in generalized vitiligo

at tissue level. J Eur Academ Dermatol Venereol

2004; 18:683-6.

4. Prasad AS. Zinc: An overview. Nutrition 1995;

11:93-99.

5. Shameer P, Prasad PVS, Kaviarasan PK. Serum zinc

level in vitiligo case control study. Letter to Editor,

Ind J Dermatol Venerol Leprol 2005; 71(3):206-7.

6. Bruske K, Salfeld. Zinc and its status in some

dermatological diseases- a statistical assessment

(Article in German) Z Hautkrn 1987; 62 (S-1): 125-

31.

7. Helmy MI, Gayyar MAE, Hawas S, Eissa EA. Role

of oxidative stress in the pathogenesis of vitiligo. J

Pan-Arab League of Dermatologists 2004; 15(2):97-

105.

8. Scottish Trace Element and Micronutrient Reference

Laboratory.

9. Arora PN, Dhillon PS, Rajan SR, Sayal SK, Das AL.

Serum zinc levels in cutaneous disorders. Medical

J Armed Forces India. 2002; 58(4): 304-6.

18

Serum Zinc level in patients with Vitiligo in a Tertiary Hospital in Bangladesh BJM Vol. 21 No. 1

Introduction

Acute liver failure is defined as the presence of acute

liver disease associated with significant coagulopathy,

which has been arbitrarily defined by a prothrombin

time or factor V level of less than 50% of normal.

Fulminant hepatic failure is acute liver failure

associated with hepatic encephalopathy developing

within 8 weeks of illness.1 It is a multiorgan failure

syndrome with dramatic clinical features and often

fatal outcome. Acute viral hepatitis is the most

common cause.2 Others are drugs, chemical, poisons,

ischemia, hypoxia and metabolic abnormality.3

Histologically it is characterized by massive

parenchymal necrosis. Altered mental status

accompanied by jaundice is a hallmark of acute liver

failure. Most patients with fulminant hepatic failure

demonstrate features of multiorgan failure including

shock, renal failure, respiratory distress syndrome

and infection. Since there is no specific treatment

with proven efficacy, the principle of therepy in acute

STUDY ON AETIOLOGY AND OUTCOME OF

FULMINANT HEPATIC FAILURE IN BANGLADESHI

PATIENTS

SWADESH KUMAR CHAKROVORTTY 1, RAJIB BARUA 2, DEWAN SAIFUDDIN AHMED3, MOHAMMAD ABUL

KALAM AZAD4, ABU BAKAR SIDDIQUE5, MD. ABUL KALAM AZAD 6

Abstract

Fulminant hepatic failure is although uncommon but not rare in Bangladesh. It is the severe form of

acute hepatitis. This study was done to know the clinical presentation, aetiological background,

various complications and outcome of fulminant hepatic failure in Bangladesh. Total 28 patients

were included in the study, of them 71% were female and 29% were male. Half of the total patients

were in the age group of 16-25 years. Among the female patients 7 (35%) patients were pregnant.

The chief symptoms were jaundice, anorexia, nausea, vomiting and encephalopathy and 25%

developed bleeding manifestations. 19% patients developed renal failure, 40% had hyponatraemia

and 15.7% had hypoglycaemia. The known causes were hepatitis E virus (45.8%), hepatitis B virus

(25%), hepatitis A virus (4.1%) and antitubercular drugs (Isoniazide/Rifampicin) in 7.1% cases.

Pregnancy appears to be a risk factor for HEV induced fulminant hepatic failure. Prolonged

prothrombin time and raised serum bilirubin level were important prognostic factors but grade of

encephalopathy failed to be proved as a prognostic factor. Thereby improving sanitary facilities,

active immunization against HBV and HAV can prevent the incidence of fulminant hepatic failure

and close monitoring of renal function, serum electrolytes and blood glucose can reduce significant

mortality.

Key words: Fulminant hepatic failure, aetiology, outcome

1. Registrar, Cardiology Department, NICVD

2. Medical officer, Gastroenterology Department, BSMMU.

3. Associate Professor, Department of Gastroenterology, BSMMU.

4. Medical officer, Department of Medicine, BSMMU.

5. MD Gastroenerology( Thesis ),BSMMU.

6. Associte Professor, Department of Medicine, BSMMU.

liver failure includes intensive care for maintenance

of blood glucose, serum electrolytes and other

biochemical parameters and supportive therapy for

complications.4 Hepatic transplantation is considered

for patients reaching grade III or IV encephalopathy

due to FHF. The prognosis depends on aetiology, level

of consciousness at presentation and prothrombin

time. In FHF the hepatic pathology is potentially

reversible and survivors usually recover completely.1

The aims and objectives of the study were to evaluate

the clinical features, complications, prognostic

indices and outcome of fulminant hepatic failure in

Bangladeshi patients. Also to find out the aetiology

of the disease and to compare its features with that

of other studies at home and abroad.

Materials and methods

This study comprised of 28 patients with fulminant

hepatic failure of whom 20 were female and 8 were

male patients. The patients were collected from

different units of medicine wards (n=27) and pediatric

Bangladesh J Medicine 2010; 21 : 29-33

ward (n=1) of Dhaka Medical College Hospital from

January 2005 to January 2006. History taking and

physical examination of each patient were done

properly and was recorded in a printed data sheet.

During physical examination attention was given to

find out the stigmata of chronic liver disease to

exclude preexistent liver disease. Biochemical,

hematological investigations were done to establish

the diagnosis and for prediction of prognosis and

development of complications. Viral markers for

hepatitis A, B. C and E were done to find out the

aetiology. Patients were treated by supportive therapy

and followed up in the ward till they recovered or

expired. Improvements were assessed clinically

(reduction of jaundice, increase in liver span and

improvement of grade of encephalopathy) and

biochemically (by S. bilirubin, prothrombin time). The

mean duration of follow up was 3±1 week.

Data were entered systematically into computer with

Microsoft Excel and the test statistics used to analyze

the data were descriptive statistics.

The study was approved by the ethical review

committee of the institution.

Results and observations

Total 28 patients of fulminant hepatic failure were

selected for the study. 14 (50%) patients were in the

age group of 16-25 years and 7 (25%) patients were in

26-35 years. (Figure1). 20 (71%) patients were female

and the rest 8 (29%) patients were male. The male to

female ratio was 2:5 (Figure2). Among the female

patients 7 (35%) patients were pregnant.

Regarding the duration of illness from the onset of

jaundice to the time of presentation, 12 (42.8%)

patients presented within 7 days, 8 (28.5%) patients

from 8th to 14th day, 5 (17.8%) patients from 15th to

21st day and the rest 3 (10.7%) patients presented

from 22nd to 28th day.

All patients presented with jaundice with anorexia,

nausea, vomiting and encephalopathy. 7 (25%)

patients developed bleeding manifestations in the

form of haematemesis, melaena, haematuria or

pervaginal bleeding. 6 (21.4%) patients had

hepatomegaly and fever. 4 (14.2%) patients had

ascites. Table 1 showing the presenting features of

the patients

Table-I

Presenting features of the patients (n=8)

Features Number of patients Percentage

(n=28)

Jaundice 28 100

Encephalopathy 28 100

Anorexia/nausea/vomiting 28 100

Hepatomegaly 6 21.4

Ascites 4 14.2

Bleeding(Gastrointestinal

or genitourinary bleeding) 7 25

Fever 6 21.4

During presentation 1 (3.5%) in grade ², 6 (21.4%) in

grade ²², 7 (25%) in grade ²²² and the rest 14 (50%)

patients were in grade IV encephalopathy.

Serum bilirubin level of the study population showed

two third (74.9%) patients had between 5 and 20 mg/

dl, 4 (14.2%) had below 5 mg/dl and 3 (10.7%) had

above 20 mg/dl. Serum ALT level of 25 patients showed

12 (48%) patients had between 200 and 1000 U/L, 4

(16%) had less than 200 U/L and 3 (12%) patients

had above 2000 U/L. Prothrombin time was done in

24 cases showing two third patients had level below

50 sec and one third patients had above 50 sec. Serum

electrolytes were done in 20 (71.4%) patients. Out of

them 8 (40%) patients developed hyponatraemia and

3 (15%) patients developed hypokalaemia. Serum

creatinine was done in two third (75%) patients,

among them 4 (19%) patients had renal failure. Blood

sugar was estimated in 19 (67.8%) patients and 3

(15.7%) of them had hypoglycaemia.

Fig.-1: Age distribution of the patients

Fig.-2: Sex distribution of the patients

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Study on Aetiology and Outcome of Fulminant Hepatic Failure in Bangladeshi Patients BJM Vol. 21 No. 1

Viral markers for hepatitis A, B, C and E were done in

24 (85.7%) cases. Among them 11 (45.8%) were

hepatitis E virus positive, 6 (25%) patients were

hepatitis B virus positive and 1 (4.1%) patient was

positive for hepatitis A virus. No patient was hepatitis

C virus positive. In 2 (7.1%) cases fulminant hepatic

failure was due to drug (antitubercular) toxicity. In 4

(16.6%) cases no cause could be identified.

Among 28 patients outcome of 4 patients could not

be known as they left the hospital by discharge on

risk bond. Of the remaining 24 patients, 14 (58.3%)

patients survived and 10 (41.6%) expired.

Of the 24 patients with known outcome, 7 patients

were in grade I or II encephalopathy and among them

4 (58%) recovered from the disease. 17 patients were

grade III or IV encephalopathy and 10 (59%) recovered

from the disease.

10 patients presented within 7 days of illness and 2

(20%) of them expired. 14 patients presented after 7

days and 8 (57%) of them expired (Figure3).

Prothrombin time was measured in 24 cases and

among them outcome of 21 patients could be known.

15 patients had prothrombin time <50 seconds and 3

(20%) of them died. 6 patients had prothrombin time

>50 seconds and 5 (83.3%) of them died (Figure4).

11 patients had serum bilirubin <10 mg/dl and 3

(27.2%) of them died. 13 patients had serum bilirubin

>10 mg/dl and 8 (61.5%) died (Figure5).

13 patients had serum ALT<1000 U/L and 7 (53.8%)

of them survived. 8 patients had serum ALT >1000

U/L and 7 (87.5%) of them survived.

Among the 6 patients with disease caused by hepatitis

B virus, 3 (50%) survived. Of the 11 patients with

disease caused by hepatitis E virus, 6 (54%) survived.

Only 1 patient in the study affected by hepatitis A

virus survived. Among the 2 patients due to anti

tubercular chemotherapy, 1 patient survived and the

other died. 4 patients were due to unknown cause

and 3 (75%) of them survived.

Among the female patients 7 were pregnant during

the attack, 5 (71.4%) patients of them were due to

hepatitis E virus and 3 (60%) of them expired.

Discussion

Acute liver failure is a dramatic, unpredictable and

often devastating clinical .condition. Acute viral

hepatitis is the most common cause. In the study

most of the patients (75%) were in the age group of

16-35 years. It is similar to the finding of Khan M et

al. 71% were female and 29% were male with M:F=

2:5. It is contrary to the finding of Khan M et al where

M:F was 3:1.3

Anorexia, nausea, vomiting, jaundice and altered

conscious level were the predominant features. These

features have also been recognized in studies by Lee

WM5 and Khan M et al.3 In the current study all the

patients presented within 4 weeks of the onset of

illness which is consistent the finding of Khan M et

al where all patients presented within 2 weeks of the

onset of illness.3 Bleeding from different sites is the

end result of the coagulopathy. Marison G et al.

reported bleeding from 50% cases but in our study

28.5% patients showed bleeding manifestation.6

Wilkinson SP et al. recorded 55% functional renal

failure in patients of fulminant hepatic failure.7 In

the present study 19% patients developed renal

failure which is much lower. We found hyponatraemia

in 40% patients but Khan et al3 reported 66% patients

with hyponatraemia which is much higher than our

observation. 15.7% of our patients developed

hypoglycaemia which is consistent with the result of

Khan M et al.3 They recorded hypoglycaemia in 8%

patients.

Fig.-3: Relationship between the duration of onset of

encephalopathy and death rate

Patients admitted after

7 days

Patient admitted within

7 days

Prothrombin time <50 sec Prothrombin time >50 sec

Fig.-4: Relationship between serum prothrombin time and

death rate

Serum bilirubin <10 mg/dl Serum bilirubin >10 mg/dl

Fig.-5: Relationship between serum bilirubin level and

death rate

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BJM Vol. 21 No. 1 Study on Aetiology and Outcome of Fulminant Hepatic Failure in Bangladeshi Patients

In this study hepatitis E virus was the causative agent

in 45.8% cases and hepatitis B virus in 25% cases.

Fulminant hepatic failure due to hepatitis E virus is

rare in Western countries, reports from developing

countries showed that HEV is the common cause of

FHF.8 Sallic R et al reported only 16.6% of patients

with FHF in UK due to HEV infection9 but no cases of

FHF due to HEV from France, Germany and USA.10

Acharya SK et al showed 62% cases of HEV was the

causative agent of FHF.8 Mathiesen LR et al showed

hepatitis B virus as a causative agent of FHF in 30-

40% cases in western population.11 Khan et al.

recorded 38.7% of FHF was due to HBV in

Bangladesh.3

Among the 7 pregnant patients 71.4% were due to

HEV infection and 60% of them died. This is clearly

related to the observation of Acharya SK et al. who

showed that HEV induced FHF is more common in

pregnancy and carries a high mortality rate.12

Hepatic encephalopathy of varying grades is the

hallmark of FHF. In this study there was no significant

difference in survival among the patients of different

grades of encephalopathy. Survival rate of patients

having encephalopathy grade 1 and 2 was 58% and

grade 3 and 4 was 59%. Khan et al showed none of

grade 4 encephalopathy survived and Trey et al showed

only 17.6% of their patients from Grade 4

encephalopathy. These results are in contrary to our

findings.3,13

83.3% of the patients having prothrombin time >50

sec died and 20% of the patients having prothrombin

time <50 sec expired. So prolonged prothrombin time

appears to be a bad prognostic factor which is

consistent with the finding of O’Grady JG et al. They

found 98% of patients with prothrombin time >50 sec

were expired.14

27.2% of the patients with S. bilirubin <10 mg/dl

expired and 61.5% of the patients with S. bilirubin

>10 mg/dl expired. So high S. bilirubin is found to be

a bad prognostic factor which is in contrary to the

finding of Khan M et al as they showed no prognostic

role of S. bilirubin level.3

Patients who presented within 7 days of onset of

illness, 20% of them expired and 57% of the patients

who presented after 7 days of illness expired. This is

also similar to other study. Khan M et al showed

death rates of these groups are 46.7% and 85.1%

respectively.3

Acharya SK et al12 reported Isoniazide/ Rifampicin

is the major cause of drug induced acute hepatic

failure in India which is also consistent with our

observation as 8.3% of the FHF were due to

antitubercular drug (Isoniazide/ Rifampicin) and 50%

of them died.

Conclusion

Fulminant hepatic failure is a serious complication

of acute viral hepatitis in Bangladesh. In the present

study HEV was the leading cause of FHF followed by

HBV. It reflects the observation that HEV is the main

cause of acute viral hepatitis in Bangladesh. Poor

sanitation and ignorance regarding food hygiene may

be precipitating factors. Pregnancy appears to be a

risk factor for HEV induced fulminant hepatic failure.

Blood glucose level should be regularly monitored and

appropriate measures should be taken promptly as

hypoglycaemia is common in FHF which may

complicate the disease outcome. Maintenance of

input, output chart, monitoring of renal function and

serum electrolytes are also important as alteration

of renal function as well as S. electrolytes are common

complication in FHF. Prolonged prothrombin time is

an important prognostic factor but grade of

encephalopathy failed to be proved as a prognostic

factor. This may reflect the frequent alteration of the

grade of encephalopathy which needs more close

monitoring.

As there is no specific therapy and significant

mortality rate we should try to prevent acute viral

hepatitis by creating awareness oh people, improving

sanitary facilities and by active immunization against

HBV and HAV. Thus we can reduce morbidity and

mortality related to it. Also we should actively think

of establishment of specialized liver unit by which

we can provide proper care to fulminant hepatic failure

patients as well as facility for liver transplantation

for the selected group of patients who have least

chance of survival with conservative therapy.

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