Objectives of the Study:To identify the factors causing high lactate levels in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) and to assess the association between high blood lactate levels and postoperative morbidity and mortality.Methods:A retrospective observational study including 370 patients who underwent cardiac surgeries under cardiopulmonary bypass. The patients were divided into 2 groups based on serum lactate levels; those with serum lactate levels greater than or equal to 4 mmol/L considered as hyperlactatemia and those with serum lactate levels less than 4 mmol/L. Blood lactate samples were collected intraoperatively and postoperatively in the ICU. Preoperative and intraoperative risk factors for hyperlactatemia were identified using the highest intraoperative value of lactate. The postoperative morbidity and mortality associated with hyperlactatemia was studied using the overall (intraoperative and postoperative values) peak lactate levels. Preoperative clinical data, perioperative events and postoperative morbidity and mortality were recorded.Results:Intraoperative peak blood lactate levels of 4.0 mmol/L or more were present in 158 patients (42.7%). Females had higher peak intra operative lactate levels (P = 0.011). There was significant correlation between CPB time (Pearson correlation coefficient r = 0.024; P = 0.003) and aortic cross clamp time (r = 0.02, P = 0.007) with peak intraoperative blood lactate levels. Patients with hyperlactatemia had significantly higher rate of postoperative morbidity like atrial fibrillation (19.9% vs. 5.3%; P = 0.004), prolonged requirement of inotropes (34% vs. 11.8%; P = 0.001), longer stay in the ICU (P = 0.013) and hospital (P = 0.001).Conclusions:Hyperlactatemia had significant association with post-operative morbidity. Detection of hyperlactatemia in the perioperative period should be considered as an indicator of inadequate tissue oxygen delivery and must be aggressively corrected.

Extranodal NK/Tcell lymphomas (ENKTL) are rare, aggressive lymphomas. The most common primary site of involvement is the nasal cavity, nasopharynx and paranasal sinuses. The other sites of primary involvement are skin, gastrointestinal tract and testis. Advanced disease can show lymph node, bone marrow and peripheral blood involvement. We report a case of ENKTL of the jejunum, showing peripheral pancytopenia and haemophagocytosis in the bone marrow. The intestine showed multiple intestinal perforations, with evidence of infiltration by lymphoma with coexistent strongyloides infestation. The patient showed disseminated disease in the form of lymphadenopathy and had a rapidly downhill course and expired on 5th day of admission. We also discuss the problems encountered by the pathologist in diagnosing these uncommon lymphomas.

Tuberculosis is the major public health concern globally. Cardiovascular involvement was observed in 1-2% of cases with pulmonary tuberculosis. The present study was designed to assess the ECG changes in pulmonary tuberculosis before and after anti-tuberculosis therapy. A total of 90 clinically diagnosed with sputum positive pulmonary tuberculosis cases above 21 years of age were included. Cases with abnormal findings on ECG were advised to echocardiography to detect the exact abnormality / cardiac complication due to pulmonary tuberculosis. Collected data were analysed to compare the ECG changes in pulmonary tuberculosis at the initial diagnosis and follow up for six months. In 60% of cases, the duration of symptoms was less than 6 months and in 40% cases, it was more than 6 months. ECG abnormalities was observed in 65.5% pulmonary tuberculosis cases before commencing antituberculosis therapy, whereas ECG abnormalities were noted in 34.4% of cases after completion of anti-tuberculosis therapy. Sinus tachycardia was observed in pulmonary tuberculosis cases before anti tuberculosis therapy was 42.2% and after 6 months follow up with ATT it was reduced to 11.1%. Sinus tachycardia, QRS axia+90 0 , p wave axis +90 0 , Right side axis deviation and p-pulmonale was the main abnormalities noticed in ECG before the commencement of anti-tuberculosis therapy. The values were reverted back to normal after anti tuberculosis therapy. PT cases with atypical features should be a monitor with echocardiography for early detection of cardiac complications.

4686 A 38 year old woman presented with high grade fever and jaundice for one month. Patient also had reduced appetite and loss of weight for the same period. On examination, patient had significant pallor, icterus and pedal edema. Ultrasonogram showed enlarged liver (20 cms) and enlarged spleen (17.2 cms). Patient was empirically treated for malaria. Her subsequent investigations revealed Hb 35g/dl, total leucocyte count 2×109/l, differential leucocyte count - neutro 82%, lympho 18%, platelet count − 59×109/l, and red cell indices were as follows: MCV 71.6 fL, MCH 21.6 pg/cell, MCHC 30.2 g/dl. Her reticulocyte count was 0.5%. Peripheral blood smear showed pancytopenia with moderate anisopoikilocytosis. Her total bilirubin was 4.2 mg/dl and serum ferritin was found to be 1720 μg/L. In view of pancytopenia and non-response to antimalarials, patient was treated in line of septicemia with piperacillin and tazobactam, and simultaneously a bone marrow biopsy was performed. Bone marrow biopsy subsequently revealed a hypercellular marrow with erythroid hyperplasia. Number of macrophages was increased with some showing ingested red cells (hemophagocytosis) within them. In view of fever, splenomegaly, pancytopenia, hemophagocytosis and hyperferritinemia, a diagnosis of hemophagocytic lymphohistiocytosis (HLH) was made as per HLH 2004 diagnostic criteria. Bone marrow also revealed multifocal epithelial granulomas with caseation, pointing the etiology to that of disseminated tuberculosis. Patient expired before any anti-tuberculous treatment could be instituted. Causes of HLH are broadly malignancy, collagen diseases and infections. Though malignancy and collagen diseases are common causes in the Western countries, tuberculosis is an important cause in a tropical country like India. Disclosures: No relevant conflicts of interest to declare.

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