The author discusses a case of drug induced vasculitis caused by spironolactone which is very rare complication of the drug. The authors give account on the type of vasculitis caused by drug induced allergy and also the differential diagnoses if the presentation is unusual with only hematuria and kidney injury. The benefits of Spironolactone and the side effects are also illustrated.Painful gynecomastia, hyperkalemia, hypomagnesemia, hyponatremia, or hypocalcemia are rare side effects of the

No abstract

Case History83 year-old Caucasian female with past medical history of hypertension, chronic kidney disease stage 3-4 secondary to hypertensive nephrosclerosis with minimal proteinuria, hypokalemia, and Sjugrene syndrome without extra-glandular involvement. The patient was admitted to hospital because of urinary tract infection and edema of the lower extremities. She was treated with antibiotics, and diuretics for the edema. Her blood pressure was not optimum at this visit and spironolactone 25 mg was added to her medication to control her BP, hypokalemia, and proteinuria. She was on amlodipine, frusemide, clonidine, Irbesartan, and potassium supplement. The treating nephrologist decided to try spironolactone for better control of high BP and hypokalemia and phased out the potassium supplementation. At this encounter her micro-albumin-creatinine ratio was 379.3 mg/ gr, (normal value<29.9 mg/gr creatinine). Physical examination was otherwise normal except bilateral leg edema, and high blood pressure (149/65 mmHg). Her estimated glomerular filtration rate (eGFR) was 28 ml/min).She returned to the nephrology clinic after 2 weeks for bilateral lower extremities itch, burning and painful rash involving the buttocks, upper thighs and shins bilaterally as shown in the Figures 1 and 2. The rash was palpable, purpuric nodules symmetrically distributed over the lower extremities. She was send for dermatological opinion and skin biopsy of the rash. The biopsy was consistent with leukocytoclastic vasculitis. On further questioning the patient, she recalled that she had had a similar rash long time ago when she was placed on "aldactone" and the doctor had to stop the medication because of the rash, subsequently, the rash went away. This triggered discontinuation of the spironolactone and she was treated with prednisone and topical steroids by the dermatologist. The current rash faded away in 3-4 weeks, however, she was still on 5 mg of prednisone when she was last seen in the clinic. Her laboratory values are illustrated in Table 1. Case DiscussionSpironolactone is a potassium sparing mineralocorticoid receptor antagonist (MRA) which acts on the distal tubules and collecting ducts of the kidneys and antagonizing the effect of aldosterone, thereby causing inhibition of sodium and chloride reabsorption, and potassium secretion in the distal tubules. The bioavailability of spironolactone is 73%, and it is >90% protein-bound. The drug is extensively metabolized in the liver and excreted by renal (47-57%), bile and eventually fecal route (35-41%). The elimination half-life of the drug ranges from 1.4 to 15-hours depending on the type of metabolites. It is indicated for heart failure with reduced ejection fraction, hypertension especially when associated with hyperaldosteronism, hypokalemia, precocious puberty, hirsutism and female virilization syndrome. The American geriatric association (AGS) recommends that the drug should be avoided in patients >65 years old when creatinine clearance <30 ml/minute due to increased potassium lev...

Objectives: To analyze the occurrence of malignancy in nose and paranasal sinuses and to identify the common type of nose and paranasal sinuses tumor. Study Type: Analytical study Place and Duration of Study: ENT Outpatients Department, Rai Medical College Teaching Hospital, Sargodha from 1st April 2017 to 31st March 2021. Methodology: Fifteen patients with nasal endoscopy performed for the diagnosis of tumors were enrolled. Lesion site and extent were determined through computed tomography imaging. Biopsy of each patient was performed under local anesthesia and histopathological findings were documented. Results: The mean age of patients was 55.3±3.3 years. Tumors of nose and paranasal sinuses were more common in the males (66%) than in the females (34%). It is revealed that majority of cases were diagnosed with squamous cell carcinoma 12 (80%) cases, 2 (13.3%) cases were diagnosed as adenocarcinoma and 1 (6.7%) case was diagnosed as adenoid cystic carcinoma. Conclusion: Squamous cell carcinoma was the main histopathological category of nose and paranasal sinuses tumor. Keywords: Sinonasal malignancies, Paranasal malignancies, Squamous cell carcinoma, Nose, Wood dust

Modular multilevel converters are the prominent candidates for high voltage direct current transmission systems. They offer high flexibility, modularity and flexibility in their operation. The main problem of multilevel converters are the circulating current in the converter and arm's voltage balancing in steady state and dynamic state. An easy and flexible control scheme is introduced in this study which eliminates the even order harmonics in the circulating current and reduces the circulating current. The model is implemented in Simulink/Matlab and the results confirm the efficiency of the proposed model. , the response of the controller is also presented in result section, which manifest its ability to control the current and eliminate the even order harmonics.