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Patient: Male, 45Final Diagnosis: Hepatopulmonary syndromeSymptoms: Dyspnea • edema of feetMedication: —Clinical Procedure: NoneSpecialty: Gastroenterology and HepatologyObjective:Unusual clinical courseBackground:Hepatopulmonary syndrome (HPS) is a pulmonary complication characterized by a triad of chronic liver disease, arterial hypoxemia, and pulmonary vascular dilations. Agitated saline contrast echocardiography is a simple inexpensive criterion standard procedure for confirming the diagnosis of HPS.Case Report:Here, we discuss a case of a 45-year-old male Indian patient with no medical history who presented to our hospital with exertional dyspnea, hypoxia, and classical signs of HPS. A diagnosis of cirrhosis was made on the basis of history, liver enzymes, and ultrasound, while HPS was diagnosed using transthoracic echocardiography with agitated saline.Conclusions:HPS, although a complication of cirrhosis, can be the initial presentation in undiagnosed cirrhotic patients. Thus, it is important to include HPS in differentials when dealing with cases of progressive dyspnea. Also, the possibility of a liver disease etiology should be explored in patients with unexplained hypoxemia.

Aim: The estimation of the ‘dry weight’ in a patient on haemodialysis with end-stage renal disease is an important clinical challenge to date. Physical examination has its limitations in the precise assessment of volume status. The monitoring of blood volume, natriuretic peptides, and bioimpedance spectroscopy are explored as a guide for the ultrafiltration process during haemodialysis (HD) therapy. Unfortunately, none of these methods has shown promising results when used in isolation and has serious limitations. The point-of-care lung ultrasonography has emerged recently as an adjunct to physical examination as a non-invasive, radiation-free technique to estimate extravascular lung water. In this study, the authors aimed to compare the volume status assessment in end-stage renal disease patients on HD using conventional clinical methods, bio-electrical impedance, and chest ultrasound (US). Materials and Methods: A prospective cohort study was conducted on 34 patients undergoing regular HD in the Department of Nephrology dialysis centre at the University College of Medical Sciences Guru Teg Bahadur Hospital, Delhi, India, a multi-speciality tertiary care centre. Parameters included to assess the dry weight of patients were bio-impedance spectroscopy and chest US, measured in two phases: 30 minutes before and 10–60 minutes following the HD session. Results: A total of 100 assessments were done on 34 patients over 6 months. The mean pre-HD extracellular water was 17.52±2.69 L and post-HD was 16.38±2.46 L, showing a significant reduction (<0.001). The bioimpedance analysis showed that 44% of the volume status assessments had fluid overload (≥1.1 L), even when the patients were considered to be in a state of clinical euvolemia, while 79% of the assessments had a Comet Score of ≥3 suggesting a fluid overload state. Most assessments showed a significant reduction in the number of B-lines (i.e., 62% [Comet Score of between 0–2]). The mean post-HD Comet Score was 1.73±1.36 (37%). Conclusion: Chest US to assess Comet Score is highly correlated with the clinical signs and symptoms. Lung Comet Scores can also be highly correlated with ultrafiltration volume, and thus can be used as a good marker for achieving dry weight in dialysis patients.

BACKGROUNDDiabetes mellitus is a major public health problem worldwide today. It affects the genitourinary system. It predisposes patients to a variety of urinary tract infections and has long term effects on patient health. Asymptomatic bacteriuria (ASB) in diabetic patients, its effects on renal function, microalbuminuria, hypertension are not clearly defined. This study was carried out to determine the prevalence of asymptomatic bacteriuria, its clinical and microbiological outcomes in Indian diabetic patients. METHODSTwo hundred and fifty type -2 diabetics (100 males and 150 females) without genitourinary symptoms or abnormalities were included in the study. Midstream urine samples were collected from the study participants after getting informed consent. Urine samples were examined and processed for the culture using the standard microbiological procedures. The spectrum of uropathogens causing asymptomatic bacteriuria was noted. Follow up after one year was done to evaluate clinical and microbiological outcomes. RESULTSAmong the 250 diabetic patients, 43 (17.2%) had asymptomatic bacteriuria of which 31 (72.1%) were females and 12 (27.9%) were males. Escherichia coli (37.2%) was the most prevalent organism followed by Klebsiella (13.9%), Enterococcus faecalis (9.3%), Pseudomonas aeruginosa (6.9%), Staphylococcus aureus (6.9%), Candida species (6.9%), Proteus species (4.7%) and Coagulase Negative Staphylococcus (4.7%). On follow up it was found that incidence of symptomatic UTI in the study duration was 10 (23.26%) in the group with ASB and 39 (18.84%) in patients not having ASB at baseline. Prevalence of hypertension was also similar at the end of one year in both the groups. eGFR, prevalence of microalbuminuria and macroalbuminuria was also similar in both the groups at one year of follow up. CONCLUSIONSThe overall prevalence of ASB in the diabetic patients was 17.2%. It was more common in females. Post-menopausal females have higher prevalence of ASB. E. coli was the most prevalent organism. Risk of symptomatic UTI appears to be comparable to general diabetic population. Hypertension, renal function and microalbuminuria do not appear to be affected by presence of ASB.

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