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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


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  Editorial …

8h August 2011, Monday

Drug fever: An update

Can drug be the cause of fever?

Fever can be the sole manifestation of an adverse drug reaction in 3 to 5 percent of cases. In elderly the risk increases with the number of drugs prescribed. Active HIV infection has increased susceptibility to drug reactions.

What is drug fever?

Drug fever is defined as fever coinciding with administration of a drug and disappearing after the discontinuation of the drug, when no other cause for the fever is evident after a careful physical examination and laboratory investigation.

What are the five types of drug fevers?

  • Hypersensitivity reactions
  • Altered thermoregulatory mechanisms
  • Reactions that are directly related to administration of the drug
  • Reactions that are direct extensions of the pharmacologic action of the drug
  • Idiosyncratic reactions

Can methotrexate cause fever when combined with azathioprine?

Fever is recognized when certain drugs are used in combination, such as methotrexate and azathioprine in the treatment of refractory rheumatoid arthritis.

What is fever associated with hypersensitivity?

Hypersensitivity is the most common cause of drug fever. Fever appears several days to three weeks after the drug has been started, but the lag time can be as long as several years. Fever can arise within hours of a rechallenge.

Can hypersensitivity fever present with rash?

Fever can occur alone or with rash, urticaria, hepatic or renal dysfunction, pulmonary involvement, mucosal ulceration and hematologic abnormalities.

How long the fever last in hypersensitivity drug fever?

After the drug is stopped the fever may subside within 72 to 96 hours, but delays of five to seven days can occur.

What are the most common five drugs which cases drug fever?

  1. Anticonvulsants like carbamazepine, phenytoin, phenobarbital and primidone. It occur in 1/5000 treated patients. Fever starts 5–6m days and often resembles infectious mononucleosis. After the drug is stopped resolution may take 2–6 weeks. Skin reactions often accompany fever.
  2. Minocycline: Febrile reactions can be associated with joint, lung, liver, and skin involvement, and often accompanied by eosinophilia. The reaction may occur many months to years after the drug is introduced.
  3. Antibiotics are also the most common cause of drug fever, accounting for one–third of episodes. The examples are beta–lactams, sulfonamides and nitrofurantoin.
  4. Allopurinol is an uncommon cause of drug fever. The fever is accompanied by hepatotoxicity, renal impairment. severe rash, and eosinophilia (60%). The toxicity is more common with concurrent use of thiazide diuretics.
  5. Heparin is a rare cause of drug fever. Low molecular weight heparins do not appear to cause drug fever.

What is drug fever due to altered thermoregulation?

Exogenous thyroid hormone can increase the metabolic rate and directly increase heat production. Drugs with anticholinergic activity, such as tricyclic antidepressants, atropine, antihistamines, phenothiazines, and butyrophenone tranquilizers can cause fever by disturbing central hypothalamic function. Sympathomimetic agents such as amphetamines, cocaine, and related agents disturb both central hypothalamic function and peripheral effect or mechanisms by causing peripheral vasoconstriction.

What is fever associated with drug administration?

  • Solutions containing drugs can become contaminated with endotoxin or other exogenous pyrogens.
  • Fever can also accompany a chemical phlebitis
  • Fever can follow after injections with paraldehyde, pentazocine, and other drugs.
  • Many routine vaccinations are associated with low–grade fever for 48 hours or less.
  • Amphotericin B and bleomycin have pyrogenic properties.

What is fever as an extension of the pharmacologic effect of a drug?

Fever is observed after chemotherapy for various solid tumors, lymphomas, and leukemias. Fever is due to cell necrosis and lysis. Fever commences two to three days after chemotherapy and may last for one week or more. This can be distinguished from febrile neutropenia which rarely develops before the second week after chemotherapy.

What is fever due to an idiosyncratic reaction?

  • Malignant hyperthermia is a rare event characterized by the sudden appearance of fever over 40ºC, muscle rigidity, metabolic acidosis, and hemodynamic instability during general anesthesia.
  • The neuroleptic malignant syndrome (NMS) is characterized by high fever, muscle rigidity, altered and fluctuating mental state, and dysautonomias occurring with the use of CNS dopamine depleting agents.
  • The serotonin syndrome is a distinct entity presenting as agitation, confusion, hyperthermia, and autonomic hyperactivity.
  • Fever may occur when patients with G6PD deficiency with prescribed drugs such as primaquine, quinine sulfate, or sulfonamides.
  • Hyperthermia can occur with salicylate toxicity.

What are the lab abnormalities in drug fever?

  • White blood cell count can be elevated with accompanying eosinophilia
  • ESR is usually increased
  • Liver and renal dysfunction
  • Urine can be checked for eosinophils, especially in interstitial nephritis caused by beta–lactam antibiotics.

What happens after cessation of the drug?

In most, resolution of drug fever will occur within 72 to 96 hours of discontinuing the offending drug.

What is rechallenge test?

Rechallenge with the putative offending agent can confirm the diagnosis if fever recurs. Rechallenge is usually safe.

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Dr KK Aggarwal
Group Editor in Chief

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Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal on

Drug fever: An update

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    Photo Feature (from the HCFI Photo Gallery)

National Conference on Insight
on Medicolegal Issues

Padma Shri and Dr BC Roy Awardee Dr KK Aggarwal interacting with the audience in the National Conference on Insight on Medicoleagl Issues held on 10th July, 2011.

Dr K K Aggarwal
    National News

National Conference on Insight on Medico Legal Issues – For the First time any conference was posted live on Facebook & Twitter


MONSOON OUTBREAK: Gastro, first cholera case

The spurt in gastroenteritis cases this monsoon has worsened with the city registering its first case of cholera–the deadly form of diarrhoea. Arshad Ansari, a four–year–old boy from Bainganwadi slum in Govandi, has tested positive for cholera. State–run J J Hospital first admitted Arshad’s eight–month–old brother on Monday, as he was suffering from severe loose motions and dehydration. A day later, his six–year–old sister was admitted over similar symptoms. On Wednesday, Arshad and his other brother, aged four and three, were also admitted. Stool samples of all the four siblings were sent for testing; only Arshad tested positive for cholera. "The child tested positive not only in the hanging drop test, but also in the ELISA test, which confirmed cholera," said Dr T P Lahane , dean, J J Hospital. (Source: TOI, Mumbai, Aug 6, 2011)

For comments and archives

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology: Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

    International News

(Dr Monica and Brahm Vasudev)

Now, a software to prevent stampedes

London: Scientists have developed a new software which can accurately detect when crowds are starting to build up to dangerous levels — a feat they say could help prevent stampede deaths that often occur during festivals and mass celebrations. German researchers who developed the new software said that it will give security staff the chance to disperse crowds to safety by pre–empting the problem. Lead researcher Barbara Krausz, from the Fraunhofer Institute for Intelligent Analysis and Information Systems, Germany, said when people become trapped in a congested area, they sway slowly from side to side in an effort to keep their balance. (Source: The Times Of India, Aug 5, 2011)

For comments and archives

New nerve cells made from skin

For the first time, human skin cells have been directly transformed into functional nerve cells, opening a way for cell replacement therapies for neurodegenerative conditions such as Alzheimer’s disease, researchers reported. Transduction using a lentivirus vector that carried the transcription-regulating genes Ascl1, Brn2, and Zic1 resulted in conversion of 62% of human fibroblasts into neuronal cells, according to Asa Abeliovich, MD, PhD, of Columbia University in New York City, and colleagues. (Source: Medpage Today)

For comments and archives

FOBT not fooled by upper GI bleeds

Bleeding in the upper gastrointestinal (GI) tract did not alter the accuracy of immunochemical fecal occult blood testing (FOBT) for lower–GI lesions, according to results of a large prospective cohort study. FOBT had a sensitivity of 24.3% and specificity of 89% for lower-GI bleeding, and twice as many patients with endoscopy–confirmed lower–GI lesions had positive FOBT results compared with patients who had negative tests. In contrast, a similar proportion of patients with positive and negative FOBT results had endoscopy–confirmed upper–GI lesions, as reported online in CMAJ. (Source: Medpage Today)

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Absolute blood flow better predictor of cardiac events

Using data on absolute myocardial blood flow reserve gained through rubidium–82 PET imaging is prognostic of death, MI, and other major cardiovascular events, a single–center study found. Patients with impaired myocardial flow reserve had higher incidences of MI and cardiac death, even when their summed stress scores (SSS) were within the normal range, reported Maria C. Ziadi, MD, from the University of Ottawa Heart Institute in Ontario, and colleagues. All cardiac deaths occurred in patients with a severely impaired myocardial flow reserve (<1.5) –– 1% in the group with normal SSS, and 6.5% in the group with abnormal SSS, according to the study published online in the Journal of the American College of Cardiology. (Source: Medpage Today)

For comments and archives

    Fitness Update

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com)

Study finds personality plays role in body weight

People with personality traits of high neuroticism and low conscientiousness are likely to go through cycles of gaining and losing weight throughout their lives, according to an examination of 50 years of data in a study published by the American Psychological Association. Impulsivity was the strongest predictor of who would be overweight, the researchers found. Study participants who scored in the top 10 percent on impulsivity weighed an average of 22 lbs. more than those in the bottom 10 percent, according to the study.

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    Twitter of the Day

@DrKKAggarwal: #AJCCare Melioidosis of the brain stem is rare. Early diagnosis and treatment is difficult.Samit Mehta et al Vol… http://fb.me/UILdLYJ6

@DeepakChopra: Realize that only the ego thinks in terms of superior or inferior. At the level of being, you are above or beneath no one.

    Dr KK Answers

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

What is fever due to an idiosyncratic reaction?

  1. Malignant hyperthermia is a rare event characterized by the sudden appearance of fever over 40°C, muscle rigidity, metabolic acidosis, and hemodynamic instability during general anesthesia.
  2. The neuroleptic malignant syndrome (NMS) is characterized by high fever, muscle rigidity, altered and fluctuating mental state, and dysautonomias occurring with the use of CNS dopamine depleting agents.
  3. The serotonin syndrome is a distinct entity presenting as agitation, confusion, hyperthermia, and autonomic hyperactivity.
  4. Fever may occur when patients with G6PD deficiency with prescribed drugs such as primaquine, quinine sulfate, or sulfonamides.
  5. Hyperthermia can occur with salicylate toxicity.

For comments and archives

    Spiritual Update

Eat less to live more – a new prescription

Eating less calories can delay primary aging. "The less you live the more you live" has been a Vedic saying. Calorie restriction has previously been shown to slow aging and increase lifespan in small mammals. Adhering to a calorie–restricted diet over the long term ameliorates the normal age–re

For comments and archives

    An Inspirational Story

(Ms Ritu Sinha)

Fences in your Mind

Excerpt from Living a Five Star Life by Betty Mahalik

I’ve watched the movie Chicken Run at least a half-dozen times. Just beneath the surface of its simplistic look and story line lie a number of wonderful messages told through the eyes of a bunch of Claymation chickens trying to break out of their chicken–wire world to escape their fate at the chopping block. Their freedom leader, a feisty little hen named Ginger, comments profoundly in one scene: "the fences are all in your mind." She reminds her fellow chickens (and us), that a bigger obstacle than the physical fences they’re surrounded by are the mental fences that hold them captive.

It’s been a good reminder for me on those occasions when I’ve been dealing with my own mental fences…those created by self–doubt, uncertainty, fear. Can you relate? Where have you fenced yourself in mentally in recent days or weeks? Perhaps your mental fence is procrastination, a deadening habit that keeps you stuck. Maybe yours, like mine, is related to self-doubt, and the on–going internal noise it produces that keeps you immobilized. Perhaps yours is the belief that you don’t deserve success, so you sabotage yourself to avoid having to find out how successful you could be. There are a million variations of the theme, but the result is still the same: we stay stuck like the chickens in the movie.

One of the key questions in the Best Year Yet program is: "How do I limit myself and how can I stop?" Those limitations are never external. They always live inside us. The antidote to being trapped by our mental fences is to create a compelling enough vision that, like Ginger and her flock of chicken friends, we're willing to resort to amazing measures to break out. The formula:

Vision + Consistent Action = Freedom!

I challenge you to take some bold, even outrageous steps to break free of your mental fences. If it’s procrastination, declare a "freedom day" and take action on everything you’ve been putting off: from cleaning your office to making phone calls or responding to emails you’ve avoided.

If it’s self–doubt, sit down and write out everything you value and why it’s important. Then challenge yourself to eliminate anything that doesn’t absolutely reflect your values, or add something that is a profound statement of who you are.

Freedom is just the other side of action.

Recognize that your mental fences can only keep you stuck as long as you’re looking at them. They can only contain you as long as you’re not taking actions consistent with your vision. Go ahead, take the action you’ve avoided and leap into a future filled with possibilities. And remember, the fences are all in your mind!

For comments and archives

    Pediatric Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

A new blood test marker may help to rule out acute appendicitis

A rapid blood test for the inflammatory marker S100A8/A9 shows potential as an aid in diagnosing acute appendicitis. S100A8/A9 is a large protein that plays a pivotal role in the acute inflammatory cascade. Diagnosis of acute appendicitis is one of the most difficult challenges for emergency physician. The assay demonstrated greater sensitivity for acute appendicitis than did either abdominal CT or white blood cell count, the most widely utilized blood test for this purpose. The assay displayed mediocre specificity, but when used in conjunction with either a WBC count or abdominal CT, the assay had a 100% negative predictive value.

For comments and archives

    Infertility Update

(Dr. Kaberi Banerjee, Infertility and IVF Specialist)

What is unexplained infertility?

Up to 26% of infertile couples have unexplained infertility. In such cases, abnormalities are likely to be present but not detected by current methods. Possible problems could be: The egg is not released at the optimum time for fertilization, it may not enter the fallopian tube, the sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization. Also, polymorphisms in folate pathway genes could be one reason for fertility complications in some women with unexplained infertility.

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    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Anti–smooth muscle antibody (ASMA)

To help diagnose chronic active autoimmune hepatitis and distinguish it from other causes of liver injury

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    IJCP Special

Dr Good Dr Bad

Situation: A diabetic smoker with A1C 6.5% came for follow up.
Dr Bad: Very good control.
Dr Good: Its good control but you should also stop smoking.
Lesson: Smoking cessation is essential for diabetic patients who are smokers.

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Make Sure

Situation: A patient after receiving 40 units of insulin developed severe hypoglycemia.
Reaction: Oh my God! The order was 4 units.
Lesson: Make sure that 4 unit is not written as 4.0 units as it may be read incorrectly as 40.

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    Quote of the Day

(Dr GM Singh)

No one can make you feel inferior without your consent. Eleanor Roosevelt

    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Lust murder

A Criminal Investigative Analysis model has been developed for investigators by Hazelwood of FBI of America one of the top researchers in the field of lust murders. On the basis of various literature and experience of two decades I endorse/feel that the dead body do tell tales ‘how he/she has been killed/died", there should be a meticulous autopsy surgeon to hear/understand its language.

  • Lust murder may be organized or disorganized depending on the psychopathology of the offender and the same is manifested in the crime scene of the killings.
  • It is determined by very close observation/examination of the scene and corpse. In the case of a disorganized offender the victim will be immediately rendered unconscious or dead by a "blitz–style" of attack and there will be evidence of symbolic and post–mortem sexual activities.
  • In both instances, however, the cutting, mutilation and overkill type wound structures will be directed towards those parts of the body that the offender finds significant to him as per his fantasy and serve as a sexual stimulus.
  • The disorganized offender usually depersonalizes his victim by facial destruction or overkill type of wounds and it became a signature forensic component for crime detection.
  • Any sexually sadistic acts are performed postmortem. Mutilation to the genitalia in females, neck, throat and buttocks are performed because these parts of the body contain a strong sexual significance to him. Most cases of lust murder usually involve male perpetrators. However, accounts of female lust murderers do exist also.

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    Mind Teaser

Read this…………………

Horner’s syndrome is characterized by all of the following except:

1. Miosis
2. Enophthalmos
3. Ptosis
4. Cycloplegia

Yesterday’s Mind Teaser: Which of the following is not true about carbon monoxide poisoning?

a) It shift the oxygen hemoglobin dissociation curve to left.
b) It kills cytochrome.
c) It increases displacement of oxygen from hemoglobin.
d) Direct action occurs on central nervous system

Answer for Yesterday’s Mind Teaser: c) It increases displacemnet of oxygen from hemoglobin

Correct answers received from: Dr Chandresh Jardosh, Dr Jainendra Upadhyay, Dr Surendra Bahadur Mathur, Dr. B. B. Aggarwal,

Answer for 6th August Mind Teaser: c. Persistent HPV infection is a major risk factor for cervical cancer.
Correct answers received from: Dr Valluri Ramarao, Dr Priya, Dr Sheetal, Dr Anuraag, Dr Vikas, Dr Rajesh

Send your answer to ijcp12@gmail.com

   Laugh a While

(Dr GM Singh)

Patient: Please tell me, doctor, am I getting better?

Doctor: I think so. But to be sure, let me feel your wallet.

For comments and archives

    Drug Update

List of Approved Drug From 01–01–2011 to 30–06–2011

Drug Name
DCI Approval Date
Ilaprazole Tablets 5mg/10mg
For the treatment of duodenal ulcer in adults only.
    Public Forum

(Press Release for use by the newspapers)

Get your Press release online http://hcfi.emedinews.in (English/Hindi/Audio/Video/Photo)

Living alone after heart attack risky

Living alone after a heart attack increases the chances of death in the next four years, said Padmashri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

Citing a recent study published in the American Journal of Cardiology, he further added that the chances of death at one year after a heart attack was roughly the same for individuals living alone compared to those living with someone else. But, patients who lived alone had 35% greater risk of death at four years after the heart attack.

Social support greatly influences the outcome of an illness. It enhances not only physical health but also mental health. Family support, including those of their friends, helps these patients to recover and have a good quality of life. Lack of social support in people who live alone hampers their recovery. They do not have the assistance they need to take their medicines, the motivation to follow the prescribed exercise regime and keep up with follow up visits to their doctor.

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    Readers Responses
  1. Dear Dr KK, For a very absorbing editorial on Nag Panchami, hearty felictations! Did you notice that somewhere in the middle of the argument you decided to 'kill' rather than 'tame' ego.  On a more prosaic level I wonder if snakes drink 'milk' or its good food material being drained in holes made by rats and other rodents?   Regards: (Er Anuj Sinha), Director, Vigyan Prasar
    Forthcoming Events

September 30th to October 2nd, 2011, Worldcon 2011 – XVI World Congress of Cardiology, Echocardiography & Allied Imaging Techniques at The Leela Kempinski, Gurgaon (Delhi NCR), INDIA

from Sept 29, 2011: A unique & highly educative Pre–Conference CME, International & National Icons in the field of Cardiology & Echocardiography will form the teaching faculty.



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