Dengue virus can co-infect with a number of viruses, bacteria, and parasites of which dengue malaria co-infection is most well-known. We report a rare case of dengue virus co-infection with typhoid fever and the development of dengue hemorrhagic fever (DHF) during a dengue outbreak. The second spike of high-grade fever following initial defervescence with antibiotic therapy, hemorrhagic manifestations, new onset leucopenia and thrombocytopenia, and evidence of plasma leakage raised suspicion of DHF. Diagnosis of dengue co-infection was made by seroconversion for anti-dengue immunoglobulin M (IgM) antibodies by enzyme-linked immunosorbent assay (ELISA) on the seventh day of new-onset fever. Early recognition and judicious use of fluid therapy prevented the patient from developing shock and its complications. Prompt diagnosis, early recognition of plasma leakage, and appropriate management of DHF can reduce morbidity and mortality.

Introduction: Diabetic patients undergoing surgery are more susceptible to hospital-acquired infection, particularly surgical site infection (SSI). Good glycemic control in preoperative patients significantly decreases the risk of SSI. There is a scarcity of data from low-income countries studying the relation between perioperative glycated hemoglobin (HbA1c) levels and postoperative SSI. We aim to establish statistical relation between HbA1c and SSI which will help decrease post-operative infections and morbidity. Methods: This study was conducted in the surgical unit of Jinnah Sindh Medical University, Karachi, Pakistan, from August 2020 to April 2022. Patients who underwent elective surgical procedures (n= 1024) were included in the study and divided into two groups based on their HbA1c levels. Patients with HbA1c levels higher than 6.5% were classified as group A and those with HbA1c less than 6.5% belonged to group B. For statistical analysis, IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States) was used. Results: Group A comprised 579 (56.5%) patients. The presence of SSI in participants with HbA1c >6.5% was statistically significant (p-value: 0.011). Genderwise comparison with the presence of SSI was found to be insignificant (p-value: 0.28). Smoking was positively correlated with the absence of SSI. No significance in terms of presence or absence of SSI was found in the comparison of the type of wounds (p-value: 0.25). Conclusion: There is a positive relationship between raised HbA1c levels and the development of SSI. Our study emphasizes the importance of the use of HbA1c levels as a more accurate predictor of glycemic control in pre-operative patients rather than blood glucose levels. It is imperative that surgeons must check HbA1c levels before selecting patients for elective surgeries, especially in low-income countries where the healthcare burden is already huge.

Primary biliary cholangitis (PBC) is an autoimmune disorder characterized by biliary destruction leading to intrahepatic biliary cholestasis. It predominantly affects women during the fifth and sixth decades. Treatment options have progressed from ursodeoxycholic acid (UDCA) and obeticholic acid (OCA) to liver and stem cell transplant. The objectives include summarizing established and new diagnostic approaches for PBC along with reviewing efficacy treatments, their side effects, and future directions. The treatment of PBC is based on risk stratification, including assessment of the patient’s age, sex, clinical pattern, biochemical and antibody profile, histology, and markers of fibrosis. UDCA and OCA are Food and Drug Administration (FDA) approved first-line and second-line agents. Elafibranor, a recently FDA-approved agent based on its efficacy, was shown in the ELATIVE trial. Seladelpar, currently under FDA review in the ENHANCE III trial, is also used in PBC. Fibrates, a third-line treatment, are found efficacious in different trials. Other treatment options are in phase II/III clinical trials. The question of whether we use immunotherapy has been answered in the NCT02376335 and NCT00746486 trials, stating that rituximab and budesonide cannot be used as no clinical significance is observed. The emergence of new therapies and the potential of combination treatments offer hope for improving outcomes for all patients with PBC. Personalized treatment strategies, continuous monitoring, and a comprehensive approach to symptom management are key to optimizing care and enhancing the quality of life for individuals affected by this chronic liver disease.

In the dawn of the modern era, hypertension is still prevalent globally. Regardless of age and gender, thiazide diuretics, calcium channel blockers, and renin-angiotensin inhibitors remain the first line of treatment. Drug-induced hyponatremia is a side effect of thiazide diuretics. At times, finding the cause of hyponatremia can be a challenging task due to the nonspecific clinical manifestations, and this can prove to be a hazard for serious morbidity and mortality. We report a case of a 75-year-old female patient with a BMI of 22.7 kg/m² and a past medical history of hypertension and hyperlipidemia who presented to our center with complaints of lethargy, weakness, and lightheadedness for five days. She was previously taking famotidine, atorvastatin, losartan, triamterene, and atenolol to manage her hypertension and hyperlipidemia. Her medication was changed to azilsartan-chlorthalidone, amlodipine, and carvedilol one week before presentation for better management of her blood pressure. Her electrolytes revealed sodium levels of 114 mmol/L, serum osmolality of 249 mOsmol/Kg (range 280 to 300 mOsmol/Kg), urine osmolality of 368 mOsmol/Kg, and urine sodium of 70 mmol/L (range 30 to 90 mmol/L). It was a new onset of hyponatremia, and her previous labs a month before the medication change were normal. The patient was discontinued on amlodipine, and the chlorthalidone component of azilsartan-chlorthalidone was discontinued. Her hydration was maintained with intravenous normal saline. The patient's health and symptoms improved after four days, along with an improvement in sodium levels. She was followed for two weeks and had been doing well. This case highlights the importance of taking a detailed history and examination, and taking into account drugs as a source of hyponatremia in elderly patients.