Herpes genitalis, caused by HSV-2, is an incurable genital ulcerative disease transmitted by sexual intercourse. The virus establishes life-long latency in sacral root ganglia and reported to have synergistic relationship with HIV-1 transmission. Till date no effective vaccine is available, while the existing therapy frequently yielded drug resistance, toxicity and treatment failure. Thus, there is a pressing need for non-nucleotide antiviral agent from traditional source. Based on ethnomedicinal use we have isolated a compound 7-methoxy-1-methyl-4,9-dihydro-3H-pyrido[3,4-b]indole (HM) from the traditional herb Ophiorrhiza nicobarica Balkr, and evaluated its efficacy on isolates of HSV-2 in vitro and in vivo. The cytotoxicity (CC50), effective concentrations (EC50) and the mode of action of HM was determined by MTT, plaque reduction, time-of-addition, immunofluorescence (IFA), Western blot, qRT-PCR, EMSA, supershift and co-immunoprecipitation assays; while the in vivo toxicity and efficacy was evaluated in BALB/c mice. The results revealed that HM possesses significant anti-HSV-2 activity with EC50 of 1.1-2.8 µg/ml, and selectivity index of >20. The time kinetics and IFA demonstrated that HM dose dependently inhibited 50-99% of HSV-2 infection at 1.5-5.0 µg/ml at 2-4 h post-infection. Further, HM was unable to inhibit viral attachment or penetration and had no synergistic interaction with acyclovir. Moreover, Western blot and qRT-PCR assays demonstrated that HM suppressed viral IE gene expression, while the EMSA and co-immunoprecipitation studies showed that HM interfered with the recruitment of LSD-1 by HCF-1. The in vivo studies revealed that HM at its virucidal concentration was nontoxic and reduced virus yield in the brain of HSV-2 infected mice in a concentration dependent manner, compared to vaginal tissues. Thus, our results suggest that HM can serve as a prototype to develop non-nucleotide antiviral lead targeting the viral IE transcription for the management of HSV-2 infections.
Suppurative fungal infection of the thyroid is an extremely rare condition even more so in an immunocompetent patient. Fungal infections of the thyroid usually occur in immunocompromised patients with hematological malignancies, recipients of bone marrow and solid organ allografts on immunosuppression, and patients with AIDS. A 65-year-old male presented with swelling in the front of the neck for 2 years. Examination revealed a 4 × 4 cm non-tender, firm swelling of the right lobe of the thyroid. The patient was taken up for a subtotal thyroidectomy. Intra-operatively, an abscess cavity with pus was found in the right lobe of the thyroid. Histopathology revealed features of fungal abscess and staining demonstrated fungal hyphae characteristic of Aspergillus ssp.
Objectives. The present study was conducted to categorise the morphological features on bone marrow aspirate cytology into common, uncommon, and atypical features in a nonendemic region which would be helpful in clinching an early and correct diagnosis especially in clinically unsuspected cases. Methods. The morphological features on bone marrow were categorized into common, uncommon, and atypical in cases of leishmaniasis from non endemic region. Results. Out of total 27 cases, 77.7% were residents of places at the height of 500 m or above and fever was the most common presentation followed by hepatosplenomegaly. Plasmacytosis, hemophagocytosis were the common cytological features while dysmyelopoiesis, presence of leishmania bodies in nonhistiocytic cells, and granuloma with necrosis were uncommon features. Aggregates of LD bodies in form of ring, floret, or strap shapes along with giant cells constitute the atypical morphological features. Conclusion. The knowledge of common, uncommon, and atypical features on bone marrow aspirate cytology is helpful in clinching an early and correct diagnosis of leishmaniasis especially in non endemic areas where clinical suspicion is low. These features will guide the pathologist for vigilant search of LD bodies in the marrow for definite diagnosis and thus will also be helpful in preventing unnecessary workups.
The purpose of stenting for tracheal lesions varies from palliation, to cure, to stabilization while a reconstructive effort heals. This article describes a technique of fabricating customised acrylic tracheal stent for a patient with tracheal stenosis. Custom made acrylic tracheal stent described in this article facilitates easy manipulation during surgery and is cost effective when compared to pre fabricated silicone or other metallic stents.
Acrylic; Tracheal stent; Stenosis; Biocompatible
Although chronic hepatitis C virus (HCV) infection has been treated with the combination of interferon alpha (IFN-α) and ribavirin (RBV) for over a decade, the mechanism of antiviral synergy is not well understood. We aimed to determine the synergistic antiviral mechanisms of IFN-α and RBV combination treatment using HCV cell culture.
The antiviral efficacy of IFN-α, RBV alone and in combination was quantitatively measured using HCV infected and replicon cell culture. Direct antiviral activity of these two drugs at the level of HCV internal ribosome entry site (IRES) mediated translation in Huh-7 cell culture was investigated. The synergistic antiviral effect of IFN-α and RBV combination treatment was verified using both the CalcuSyn Software and MacSynergy Software.
RBV combination with IFN-α efficiently inhibits HCV replication cell culture. Our results demonstrate that IFN-α, interferon lambda (IFN-λ) and RBV each inhibit the expression of HCV IRES-GFP and that they have a minimal effect on the expression of GFP in which the translation is not IRES dependent. The combination treatments of RBV along with IFN-α or IFN-λ were highly synergistic with combination indexes <1. We show that IFN-α treatment induce levels of PKR and eIF2α phosphorylation that prevented ribosome loading of the HCV IRES-GFP mRNA. Silencing of PKR expression in Huh-7 cells prevented the inhibitory effect of IFN-α on HCV IRES-GFP expression. RBV also blocked polyribosome loading of HCV-IRES mRNA through the inhibition of cellular IMPDH activity, and induced PKR and eIF2α phosphorylation. Knockdown of PKR or IMPDH prevented RBV induced HCV IRES-GFP translation.
We demonstrated both IFN-α and RBV inhibit HCV IRES through prevention of polyribosome formation. The combination of IFN-α and RBV treatment synergistically inhibits HCV IRES translation via using two different mechanisms involving PKR activation and depletion of intracellular guanosine pool through inhibition of IMPDH.
Vitamin D deficiency and vitamin D receptor (VDR) gene polymorphism, FokI, is reported to increase the risk of many cancers. Role of vitamin D and its receptor polymorphisms in ovarian cancer has not been clearly defined.
To study the levels of serum vitamin D and occurrence of vitamin D receptor gene polymorphism (FokI) in cases of ovarian cancer.
Material and methods
FokI genotyping was done by PCR-RFLP technique and vitamin D levels were estimated by chemiluminescence immunoassay.
Serum vitamin D levels were significantly (p < 0.03) lower in ovarian cancer cases as compared to controls. The homozygous (TT) and heterozygous (CT) genotype predispose to the development of ovarian cancer in Indian population (OR: 2.37, 95% CI: 1.04-5.44) as compared to the homozygous (CC) genotype. Vitamin D deficiency and VDR gene polymorphism (FokI) act non-synergistically (p value < 0.4).
Low blood levels of vitamin D and VDR receptor polymorphism (FokI) might be a risk factor for the development of ovarian cancer. Other novel ligands of vitamin D receptor might be responsible for the non-synergistic effect.
The increased use of computed tomography pulmonary angiography (CTPA) is often justified by finding alternative diagnoses explaining patients’ symptoms. However, this has not been rigorously examined.
We retrospectively reviewed CTPA done at our center over an eleven year period (2000 – 2010) in patients with suspected pulmonary embolus (PE). We then reviewed in detail the medical records of a representative sample of patients in three index years – 2000, 2005 and 2008. We determined whether CTPA revealed pulmonary pathology other than PE that was not readily identifiable from the patient’s history, physical examination and prior chest X-ray. We also assessed whether the use of pre-test probability guided diagnostic strategy for PE.
A total of 12,640 CTPA were performed at our center from year 2000 to 2010. The number of CTPA performed increased from 84 in 2000 to 2287 in 2010, a 27 fold increase. Only 7.6 percent of all CTPA and 3.2 percent of avoidable CTPAs (low or intermediate pre-test probability and negative D-dimer) revealed previously unknown findings of any clinical significance. When we compared 2008 to 2000 and 2005, more CTPAs were performed in younger patients (mean age (years) for 2000: 67, 2005: 63, and 2008: 60, (p=0.004, one–way ANOVA)). Patients were less acutely ill with fewer risk factors for PE. Assessment of pre-test probability of PE and D-dimer measurement were rarely used to select appropriate patients for CTPA (pre-test probability of PE documented in chart (% total) in year 2000: 4.1%, 2005: 1.6%, 2008: 3.1%).
Our data do not support the argument that increased CTPA use is justified by finding an alternative pulmonary pathology that could explain patients’ symptoms. CTPA is being increasingly used as the first and only test for suspected PE.
Spontaneous subcapsular liver hematoma is rare but potentially life-threatening complication of pregnancy usually associated with severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). We present here a case of such a large spontaneous liver hematoma presenting in pregnancy, but without other known associated abnormalities, which has not been described before and it resolved on itself without any intervention.
Liver hematoma; pregnancy; HELLP syndrome
Malaria may be associated with complications which may be avoided by early diagnosis and treatment. Microscopic diagnosis showing presence of malarial parasites is needed for confirmation which at times may be unreliable and requires technical expertise. The present study was conducted to statistically analyze the haematological parameters including platelet indices which can give initial hint for malarial infection and therefore prompt the laboratory physician for active search of the parasite microscopically.
A retrospective study was conducted which included 334 cases of acute malaria caused by Plasmodium vivax, falciparum and dual infection along with 100 cases of control. Routine haematological parameters along with platelet indices (MPV and PDW) which are easily available on automated cell counter were statistically analyzed to assess their role as indicators for malaria.
Leukocyte count and platelet count were significantly lower in cases of acute malaria in comparison to controls (p value <0.001). Platelet count<150×109/l showed 87.2% sensitivity, 65% specificity, 89.3% positive predictive value and 2.49 likelihood ratio for the infection. PDW of 6–10 and MPV>8 fl had 71.9% and 61.5% sensitivity and 78.2% and 77.7% positive predictive value respectively for infection. Platelet count <150×109/l and MPV>8 fl was comparatively more sensitive indicator for vivax (88% and 70.8% respectively) than falciparum (84.8% and 50.4% respectively) and PDW 6–10 was more sensitive indicator for falciparum (82.6%) than vivax (69.5%) infection.
Thrombocytopenia (<150×109/l) and low leukocyte count (<4×109/l) may be used as probable indicator for malaria in endemic countries. Higher MPV (>8 fl) and PDW of 6–10 also show considerable sensitivity for malarial infection. In addition, thrombocytopenia (<150×109/l) and higher MPV (>8 fl) was more sensitive for vivax infection while PDW 6–10 was more sensitive for falciparum infection.
This study aims to gauge the technical and soft skills of the hospital security personnel so as to enable prioritization of their training needs.
A cross sectional questionnaire based study was conducted in December 2011. Two separate predesigned and pretested questionnaires were used for gauging soft skills and technical skills of the security personnel. Extensive statistical analysis, including Multivariate Analysis (Pillai-Bartlett trace along with Multi-factorial ANOVA) and Post-hoc Tests (Bonferroni Test) was applied.
The 143 participants performed better on the soft skills front with an average score of 6.43 and standard deviation of 1.40. The average technical skills score was 5.09 with a standard deviation of 1.44. The study avowed a need for formal hands on training with greater emphasis on technical skills. Multivariate analysis of the available data further helped in identifying 20 security personnel who should be prioritized for soft skills training and a group of 36 security personnel who should receive maximum attention during technical skills training.
This statistically driven approach can be used as a prototype by healthcare delivery institutions worldwide, after situation specific customizations, to identify the training needs of any category of healthcare staff.
Hospital Security; Soft Skills; Technical Skills; Training; Statistical Analysis
Over the last few decades, obesity, diabetes, and hypertension have become main health evils. The health problems of obesity are well-recognized. However, the fact that all obese individuals are not at the same risk of developing a disease is also recognized. The apolipoprotein B (APOB) plays a central role in lipid metabolism. So we compare the association of APOB XbaI gene polymorphism and lipid profile total in obese north Indian population.
MATERIALS AND METHODS:
A total of 132 obese (body mass index [BMI] >25 kg/m2) and 132 age matched non-obese (BMI ≤ 25 kg/m2) subjects were studied after taking detailed clinical profile. Lipid profile in serum/plasma was done using commercial kits. Genetic analysis of APOB XbaI was done using Polymerase Chain Reaction-Restriction Fragment Leanth polymorphism (PCR-RFLP).
Statistical analysis was performed by Statistical Package for the Social Sciences (SPSS) (version 11.5) software (IBM Corporation). All continuous variables were expressed as mean ± SD and tested by analysis of variance test. Comparisons of categorical variables were assessed using χ2 tests or Fisher's exact test. P < 0.05 was considered as significant.
Analysis showed that obese subjects had significantly higher value of the waist-to-hip ratio, blood pressure (systolic and diastolic), and lipid profile. In APOB XbaI gene polymorphism, we did not find significant differences in genotype or allele frequencies. Moreover, none of the studied metabolic parameters (lipid profile) showed any association with the gene polymorphism.
Study reveals no considerable association of APOB XbaI gene polymorphism with obesity and lipid profile in north Indians.
Body mass index; lipid profile; obesity; polymorphism
Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory condition of the nasal passage and paranasal sinuses characterized by Th2 biased inflammation with elevated levels of BAFF, B-lymphocytes, and immunoglobulins. Since high levels of BAFF are associated with autoimmune diseases, we assessed for evidence of autoimmunity in patients with CRS.
The objective of this study was to investigate for the presence of autoantibodies in sinonasal tissue from patients with CRS.
Standardized nasal tissue specimens were collected from patients with CRS and control subjects and assayed for immunoglobulin production, autoantibody levels, tissue distribution of immunoglobulins and binding potential of antibodies in nasal tissue using a multiplexed autoantibody microarray, ELISA and immunofluoresence.
Elevated levels of several specific autoantibodies were found in nasal polyp tissue in comparison with control tissue and inflamed tissue from non-polypoid CRS (CRSsNP) (p<0.05). In particular, nuclear-targeted autoantibodies such as anti-dsDNA IgG and IgA antibodies were found at elevated levels in nasal polyps (p<0.05) and particularly in nasal polyps from patients requiring revision surgery for recurrence. Direct immunofluorescence staining demonstrated diffuse epithelial and sub-epithelial deposition of IgG and increased numbers of IgA secreting plasma cells not seen in control nasal tissue.
Autoantibodies, particularly those against nuclear antigens, are present at locally elevated levels in nasal polyps. The presence of autoantibodies suggests that the microenvironment of a nasal polyp promotes the expansion of self-reactive B-cell clones. While the pathogenicity of these antibodies remains to be elucidated, the presence of elevated anti-dsDNA antibodies is associated with a clinically more aggressive form of CRSwNP requiring repeated surgery.
Chronic Rhinosinusitis; Sinusitis; Nasal Polyps; Autoimmunity; Autoantibodies; Biomarker
To estimate the average operative blood loss in tonsillectomy and adenotonsillectomy and the various factors affecting it. A prospective study of estimation of blood loss in 100 patients who underwent tonsillectomy and adenotonsillectomy. Data collected included the age, sex, operative indication, clotting time, Hb levels and usage of pre-operative antibiotics. Cold knife dissection method for tonsillectomy and curettage method for adenoidectomy were used. Measurement by calorimetric method of estimation being simple and accurate was used for estimation. Study undertaken at a tertiary referral hospital catering to an urban, semi-urban and rural populace. Blood loss was more in males and increases as age advances both in adenotonsillectomy and tonsillectomy. Blood loss was more in fibrosed tonsils, at lower hemoglobin levels and at higher clotting times. It was less in cases who received pre-operative antibiotics. The average blood losses in males and females during tonsillectomy were 106.91 and 96.26 ml respectively. In adenotonsillectomy, the average blood losses in males and females were 81.44 and 76.82 ml respectively. In our series we found that blood loss in tonsillectomy and adenotonsillectomy depended on various factors like age, sex, the type of tonsillitis, method of dissection, hemoglobin concentration, clotting time and the use of antibiotics. All these factors must be taken into consideration while taking up patients especially those who cannot tolerate blood loss, for surgery.
Tonsillectomy; Adenotonsillectomy; Blood loss; Cold-knife dissection; Calorimetric method
This article briefly outlines the proposed national epilepsy control program. The content of the article is based on four meetings held by invitation of the Ministry of Health. Invitees by ministry – Drs. D. C. Jain, M. Gourie Devi, V. Saxena, S. Jain, P. Satish. Chandra, M. Gupta, K. Bala, V. Puri, K. S. Anand, S. Gulati, S. Johri, P. S. Chandra, M. Behari, K. Radhakrishnan, D. Bachani. Presentations were made by Dr. M. Tripathi.The program will involve all neurologists across the country in teaching and training at state levels and a central monitoring committee.
Control; epilepsy; India; national; program
A 38-year-old woman who presented with unexplained fever and pancytopenia was subjected to a bone marrow examination. Her bone marrow aspirate smear showed no obvious pathological finding except for the presence of hemophagocytosis and mild plasmacytosis. In view of hemophagocytosis, a thorough examination of the smear was conducted and revealed the presence of histoplasmosis. She was advised to undergo evaluation of her immunological status, and she tested positive for human immunodeficiency virus (HIV) infection. This case highlights that hemophagocytosis in the marrow may be an early sign of underlying disease, and that careful examination of bone marrow smears may reveal subtle infections. In addition, histoplasmosis with hemophagocytosis may be associated with pancytopenia, and hence, the HIV status of the patient should always be investigated.
Hemophagocytosis; Histoplasmosis; Bone marrow examination; Pancytopenia
To determine the clinical features, investigations, intra-operative findings, surgical approaches used and the results of the treatment for paragangliomas of the head and neck. Retrospective study of 14 cases of paragangliomas in head and neck seen over a period of 10 years including five carotid body tumors, seven glomus jugulares and two glomus tympanicums. HRCT scans and bilateral carotid angiography were done in all cases of glomus jugulare. Pre-operative embolization was done in most cases. The trans-cervical approach was used for all cases of carotid body. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare tumors. Postaural tympanotomy approach was used for both patients with glomus tympanicum. In one case of extratympanic glomus jugulare tumor with hypoglossal palsy, a neck exploration was done to isolate and excise the tumor. Five patients with carotid body tumors presented as unilateral, painless, pulsatile swelling in the upper neck. Intra-operatively, three of the tumors were classified into Shamlin’s Grade II and one each into Grade III and Grade I. A carotid blow-out occurred in one of the patients with Grade II disease, which was managed. ECA resection had to be done in one case. Seven patients were diagnosed to have glomus jugulare and two with glomus tympanicum. Six glomus jugulare tumors presented with hearing loss, ear discharge and obvious swelling. Glomus tympanicums presented with hearing loss but no bleeding from the ear. On examination, tumors presented with an aural polyp with no VII nerve deficits. Both tympanicums were classified as Fisch Type A, three of the jugulares classified as Type B, two as Type D2 and one as Type D1. Tumors were found to be supplied predominantly by the ascending pharyngeal artery. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare. The transcanal approach was used for both patients with glomus tympanicum. Paragangliomas are uncommon tumors that need accurate diagnosis and skilled operative techniques. Though the surgical approaches may appear complicated, the removal provides good cure rates with minimal morbidity and recurrence. Lateral skull base approaches should be the armamentarium of every head and neck surgeon.
Paragangliomas (PGs); Glomus jugulare; Tympanicum; Carotid body tumors (CBTs); Lateral skull base surgery; Fisch approach
Studies have compared the role of bone marrow aspirate cytology and trephine biopsy for diagnosing various hematological disorders but fewer studies have compared the relative value of imprint cytology with aspirate and trephine biopsy. The present study was conducted to compare the role of bone marrow aspirate, touch imprint and trephine biopsy to formulate an effective and rapid method for diagnosing wide spectrum of hematological diseases. The study included total 565 cases of bone marrow examination from January 2006 till May 2010. All the smears and sections were reviewed for morphological details and findings on aspirate, imprint and biopsy were compared to each other. The diagnostic accuracy of bone marrow aspirate was 77.5%, imprint cytology 83.7% and that of biopsy was of 99.2%. The study showed 78% positive correlation between aspirate and biopsy and 84.3% between imprint and biopsy; 93.3% cases of metastatic solid tumors were correctly diagnosed on imprint while only 70% cases were diagnosed on aspirate cytology. The study concludes that all the three preparations of aspirate, imprint and biopsy complement each other. The assessment of iron status by Perl's stain is most suitable on aspirate smears but trephine biopsy remains the gold standard for diagnosing granulomatous inflammation and hypoplastic/ aplastic anemia. Meticulously prepared imprint smears not only provide cellular composition of marrow but may also be helpful in defining the architecture of marrow especially in cases of metastatic solid tumors. Imprint cytology smears should be standard practice for evaluating any marrow.
bone marrow aspirate; imprint cytology; trephine biopsy.
Mucoadhesive polymeric (carbopol 934) suspension of ciprofloxacin was prepared by ultrasonication and optimized with the aim of developing an oral controlled release gastro-retentive dosage form. The qualitative analysis of the formulation was performed by fourier transform infrared spectroscopy (FTIR), Raman spectroscopy, X-ray powder diffraction (XRD), and scanning electron microscopy (SEM) analyses. FTIR (400 cm-1 to 4000 cm-1 region) and Raman (140 to 2400 cm-1 region) Spectroscopic studies were carried out and the spectra were used for interpretation. XRD data of pure drug, polymer and the formulation were obtained using a powder diffractometer scanned from a Bragg's angle (2θ) of 10° to 70°. The dispersion of the particle was observed using SEM techniques. The particle size distribution and aspect ratio of particles in the polymeric suspension were obtained from SEM image analysis. The results from FTIR and Raman spectroscopic analyses suggested that, in formulation, the carboxylic groups of ciprofloxacin and hydroxyl groups of C934 undergo a chemical interaction leading to esterification and hydrogen bonding. The XRD data suggested that the retention of crystalline nature of ciprofloxacin in the formulation would lead to increase in stability and drug loading; decrease in solubility; and delay in release of the drug from polymeric suspension with better bioavailability and penetration capacity. The SEM image analysis indicated that, in the formulation maximum particles were having aspect ratio from 2 to 4 and standard deviation was very less which provided supporting evidences for homogeneous, uniformly dispersed, stable controlled release ciprofloxacin suspension which would be pharmaceutically acceptable.
Carbopol 934; ciprofloxacin; mucoadhesive suspension
Papillary carcinoma of thyroid (PCT) is the most common type of thyroid malignancy and metastasis to cervical lymph nodes is very common . Blood borne metastases from PCT are less frequent than with the other thyroid carcinomas . Uncommon sites include lungs, bone, atrium, cerebrum, kidney, skin .
We report four cases of papillary carcinoma with uncommon sites of metastasis.
One showed tumor emboli of 2.5 cm in internal jugular vein, one had tumor deposit in metacarpal bone and lung, one had a subcutaneous tumor deposit and one was a micropapillary carcinoma with metastasis axillary nodes. All these four cases were classical PCT.
Papillary carcinoma; Metastasis; Tumor thrombi; Internal jugular vein; Bone; Lung; Skin
The objective of this study was to evaluate the influence of caries detection dye on the in-vitro tensile bond strength of adhesive materials to sound and carious affected dentin.
Materials and Methods:
Forty healthy and carious human molars were ground to expose superficial sound dentin and carious affected dentin. Caries Detector dye was applied to sound and carious affected dentin and rinsed. Subsequently the dentin was etched with 37% phosphoric acid and rinsed leaving a moist dentin surface. The adhesive (Single bond) was applied in single layers and light cured. A posterior composite (Filtek Z 250) were used to prepare the bond strength specimens with a 3 mm in diameter bonding area. Control and experimental groups were made with and without application of dye respectively. Each group includes both sound and carious affected dentin. After 24 hour immersion in distilled water, tensile bond strength (MPa) was measured using an Instron testing machine.
Analysis of variance (ANOVA) was used to evaluate the data. The tensile bond strength were significantly less in experimental subgroup than control subgroups.
The tensile bond strengths were higher in sound and carious affected dentin without application of caries detection dyes.
Caries detector dye; posterior composite; single bond; sound and carious affected dentin
The incidence of multiple primary cancers is reported to be between 0.3% and 4.3%. The second primary lesion is identified either simultaneously with the primary lesion (synchronous) or after a period of time (metachronous). Few cases of metastasis of breast carcinoma to the esophagus and vice versa have been reported in the past.
We report an extremely rare case of a 55-year-old Indian woman who had carcinomas in both the esophagus and the breast simultaneously. She was treated successfully using combined modalities of surgery, chemotherapy and radiation therapy.
Cases of synchronous double malignancies can be treated by dealing with the malignancy in the two sites as independent carcinomas. We have to take into consideration the total dose of radiation to a critical organ as well as the effect of the total dose of toxic chemotherapeutic drugs on our patient.
Acute cholecystitis leading to gallbladder perforation is relatively common. However, transhepatic perforation of the gallbladder leading to biliary peritonitis is very rare. We present a rare case of biliary peritonitis caused by transhepatic perforation of the gallbladder.