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Paroxysmal nocturnal hemoglobinuria can rarely present as cerebral ischemia and stroke due to arterial thrombosis. However, it should be considered in a young patient with bone marrow failure features, systemic thromboses, and hemolysis. The variants of paroxysmal nocturnal hemoglobinuria pose a diagnostic challenge and hence are important to recognize. We report a case of a 28-years-old female with Herlyn Werner Wunderlich Syndrome who presented with an ischemic cerebrovascular accident, pancytopenia, hemoglobinuria, and widespread abdominal thromboses suggestive of paroxysmal nocturnal hemoglobinuria. The patient was managed symptomatically and referred toa hematologist.

BackgroundThe global incidence and prevalence of chronic kidney disease (CKD) is skyrocketing. In Asia, the prevalence of CKD varies from 10%-18%. However, as Asia is largely populated by developing countries with nascent health care systems, there is a dearth of research and data. It is estimated that a large number of cases go unreported. As a result, the exact disease burden remains unclear. The knowledge about risk factors and their proportionate role in CKD is indispensable in regards to patient management and care. ObjectiveThe early recognition of the most important risk factors for end-stage renal disease (ESRD) is key to early diagnosis, successful treatment, and general heightened awareness regarding CKD. In developing countries, the provision of medical services, in general, and nephrological services, in particular, is wholly inadequate. The insufficiency of solid and regularly updated data compounds the problem. This research study aims to partake in catering to that need. MethodologyA structured questionnaire was used to obtain quantitative and categorical data from 119 ESRD patients in the nephrology ward, Allied Hospital, Faisalabad through non-probability sampling. Socio-demographic profile of the patients and information regarding the presence or absence of risk factors were collected. The resulting dataset was analyzed using R version 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria) for data visualization and descriptive analysis. ResultsThe most common age group for ESRD presentation was 46-60 years (52.1%). Among the 119 ESRD patients, the most frequent risk factor was hypertension with 85.7% of the patients presenting with the condition, followed by diabetes mellitus (DM) in 54.6%, renal calculi in 28.6%, glomerulonephritis (GN) in 31.1%, Family history of CKD in 24.4%, and polycystic kidney disease (PKD) in 5% of the patients. Gender-wise distribution of the patients shows that the proportion of patients with hypertension, renal calculi, and family history of CKD varied very little among the two groups. ConclusionIn conclusion, our study has reinforced the existing body of knowledge and brought some fresh evidence regarding the prevalence of risk factors in ESRD to light. Hypertension and DM, together, represent the vast majority of cases with ESRD. However, hypertension far outpaces DM as the leading risk factor. Nephrolithiasis was also present in a considerable minority, with a figure much higher than previously reported. Finally, a relatively younger age group (45-60 years) formed the majority of the ESRD patients which is a concerning development. It points to early progression of CKD to ESRD. Long-term adequate control of these risk factors limits disease progression.

Vaccines have played a central role in minimizing new infections, the rate of hospitalizations, and the overall burden on the health sector. Fear of side effects is the biggest and commonest reason for avoiding getting vaccinated. It is, therefore, essential to maintain the clarity and consistency of message, to support and encourage people to get vaccinated. This study aims to contribute in that regard, by registering and quantifying the early side-effects of the Oxford-AstraZeneca COVID-19 vaccine in Pakistan. This study employs a non-random cross-sectional design. Data collected from 477 participants using a structured questionnaire was used to investigate the relationship between socio-demographic characteristics and side effect profiles of the participants. Binomial Logistic Regression was used to analyze the data. Odds Ratio (OR) gives the likelihood of having a side effect versus the reference group. Significance level (α) for the probability value (p-value) is set at 0.05. Fever (30.19%) was the most commonly experienced side effect, followed closely by fatigue (22.01%). 71.11% of those with fever experienced low grade fever (99-100F) while 62.69% of body aches experienced were moderate in intensity (Grades 4-6). In general, younger people are significantly more likely (p=0.023) to experience side effects (OR -1 = 1.023: interpreted as 1.023 times increase per unit decrease in age). Similarly, they are more likely (p= 0.029) to have a headache (OR -1 =1.039). Also, they are more likely (p= 0.007) to have a body ache (OR -1 =1.038). The Oxford-AstraZeneca COVID-19 vaccine side-effects seem to be more prevalent among younger age groups, which points to increased vaccine safety among older individuals that are usually more susceptible to severe COVID-19 infection. In addition, we found a substantially reduced number of side-effects, as compared to the clinical trials, which is an encouraging indicator for vaccine safety.

Introduction: Tuberculous meningitis (TBM) is fatal in approximately one-third of patients, and the sequelae of the disease in those who survive is challenging. It should be suspected in people residing in endemic areas with meningitis features. However, diagnosis of TBM is still a daunting challenge because it is usually based on clinical suspicion, cerebrospinal fluid findings, imaging techniques, and response to anti-tubercular therapy. Stroke is a rare complication of TBM, and it usually involves multiple areas supplied by perforating and cortical branches of the cerebral circulation rather than particular zones. Patient concerns: A 17-year-old male presented to the outpatient unit with fever and headache for 7 days, and altered sensorium for 1 day. The patient was unable to recognize his friends and family for 1 day and occasionally showed aggressive behavior. On examination, the patient had neck rigidity, positive Kernig's sign, and diminished breath sounds in the right lower zone of the right lung. Diagnosis: The patient was diagnosed with smear-negative TBM with pulmonary focus, which later developed into an ischemic stroke. Outcomes: The patient was treated with antitubercular therapy as per the national tuberculosis management protocol. Aspirin was added for stroke prevention and levetiracetam for seizure control. Conclusion: Stroke due to cerebral infarction can develop in a significant proportion of TBM patients, including adolescents. Hence, clinicians should have a high degree of clinical suspicion of TBM in endemic settings to prevent fatal complications such as stroke that may arise due to delayed diagnosis and treatment.