Isoniazid as part of Directly Observed Treatment-Short course (DOTS) regimen is universally used. Although, associated psychosis in certain cases is documented earlier, type of symptoms and onset of symptoms remains highly variable. We describe a case of 54-year-old female on anti-tubercular therapy with onset of psychosis within three days of Isoniazid initiation characterised by agitation, loosening of association, echolalia with spontaneous remission after drug stoppage. This case highlights the importance of remaining vigilant and considering isoniazid as possible causative agent for psychosis even within days of its intiation and avoiding delay in management.

Leflunomide is an immunomodulatory drug exhibiting anti-inflammatory, anti-proliferative and immunosuppressive effects. It has been widely used for treatment of active rheumatoid arthritis. Despite its good safety profile cutaneous side effects like alopecia, eczema, pruritis and dry skin have been reported with Leflunomide use. Skin ucleration, vasculitis, lichenoid drug rash and Subacute Cutaneous Lupus Erythematosus (SCLE) have been rarely reported with its use. A rare case of Leflunomide induced SCLE is being reported in a female patient with rheumatoid arthritis. The clinical features, histopathological and immunological characteristics were consistent with drug induced SCLE. Withdrawal of Leflunomide along with short course of topical steroids resulted in resolution of symptoms suggesting the drug to be the culprit. As this drug comes into widespread use, it remains to be seen whether more cases of DI-SCLE will occur/be reported. Fortunately, such a condition till times appears rare and is reversible once the drug is discontinued thus avoiding over evaluation and over treatment if the triggering drug is recognized.

A 30-year-old male diagnosed as a case of dengue fever, presented to the emergency department with high grade fever of two days duration with marked weakness in both the legs (unable to stand) and bleeding from oral and nasal cavities. The patient was febrile, vitals were stable and physical examination revealed evidence of hepatomegaly. His initial investigations showed Non-Structural Protein 1 (NS1) Antigen positive, Hemoglobin 14.6gm%, Total Leucocyte Count (TLC)-4500/cumm, Differential Leucocyte Count (DLC)-80% polymorphs, 15% lymphocytes, 3% monocytes and 2% eosinophils; platelet count of 50,000/cumm with a normocytic normochromic blood picture and International Normalized Ratio (INR)-1.29. Ultrasound showed liver of size 17.2cm with fatty infiltration, gallbladder slightly oedematous whereas, size of spleen, kidneys and pancreas was within normal limits. Patient was treated symptomatically with intravenous fluids, platelet transfusions and anti-pyretics and his general condition improved and he became afebrile, although his platelet count was consistently between 30,000 and 60,000/cumm. But on fourth day of admission patient developed intense pain in the right iliac fossa referred to back. The pain was of continuous type, associated with marked nausea, and not relieved by medication. Additionally he had developed breathlessness and abdominal distension. Physical examination revealed he was afebrile, had developed pallor, mild icterus and a distended abdomen with marked tenderness; bowel sounds were sluggish and air entry was decreased in bilateral lung fields.Laboratory investigations revealed a complete haemogram of Hemoglobin (Hb)-3.5gm%; TLC-10,000/cumm, with predominant neutrophilia and platelet count of 20,000/cumm, serum bilirubin-3.9mg%; SGOT/SGPT were 95/90 IU; serum alkaline phosphatase-132 IU; serum proteins-4.9gm%; Prothrombin Time Index (PTI)-1.2; and serum creatinine-1.1mg%. Serology was negative for HIV, HBsAg and anti-HCV. The second ultrasound showed free fluid in the abdomen, bilateral pleural effusion and alteration in the echotexture of liver and kidneys and a hypoechoic lesion of 14cm by 6cm size lateral to right kidney in the right pararenal space extending along right psoas muscle; possibly retroperitoneal haematoma. Follow-up CT abdomen showed possibility of an intra-parenchymal haematoma in the liver with extension to right peritoneum and right psoas muscle haematoma. Active extravasation of contrast on CT scan suggestive of active bleeding was not found [Table/ Fig-1]. Surgeon opined for conservative management. Patient was given prophylactic antibiotics, multiple blood transfusions including platelet transfusions and other supportive care. His symptoms and platelet count slowly improved to normal in a week. He was discharged in stable condition with advice to follow-up especially for sonography of the intraabdominal collection. His thrombophilia profile done after 6 weeks of discharge from the hospital was reported normal. DIsCUssIoNAlthough spontaneous hematomas have been describ...

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