Molecular appraisal of Giardia intestinalis from Western India: A prospective observational study

Background

Giardia intestinalis is an intestinal protozoan which commonly causes parasitic gastroenteritis globally. It is a species complex consisting of at least eight assemblages (genotypes). In India, Giardia is mostly underreported and missed in asymptomatic cases.

Aim

The aim of this study was to genotype the G. intestinalis isolates from stool samples of patients at a tertiary care center in Rajasthan, India, and to clinically correlate it.

Methods

This prospective pilot cross-sectional study was conducted from 2019 to 2021 in a tertiary care center in western India. Patients who were microscopically positive for giardiasis were enrolled. DNA was extracted from their stool samples and amplified by polymerase chain reaction (PCR) using 4E1-HP as the target sequence. Anthropometric measurements and analysis were done for children by using Anthrocal application.

Results

A total of 50 patients were enrolled. Diarrhea was present in 18 patients (36%). Among these, 6 were immunocompromised and had different comorbidities. Among the children <12 years of age, 55.17% (n = 16/29) were stunted (<-2 S.D.), and among <5 years, 44.4% (n = 4/9) showed wasting (<-2 S.D.). A PCR product corresponding to assemblage B of G. intestinalis was amplified in 47 stool specimens. Only three stool samples were negative for both assemblages A and B and posed an interesting enigma.

Conclusion

In this study, a predominance of assemblage B of G. intestinalis was detected in 94% of the isolates. Furthermore, the possibility of zoonotic transmission could not be ruled out.

Metformin mediates MicroRNA-21 regulated circulating matrix metalloproteinase-9 in diabetic nephropathy: an in-silico and clinical study

Metformin is commonly used as an oral hypoglycaemic agent in type 2 diabetes mellitus (T2DM). MicroRNA-21 is widely studied in diabetic and diabetic nephropathy (DN) patients. Matrix metalloproteinase-9 (MMP9) is involved in extracellular matrix degradation and tissue repair processes. However, the effect of metformin administration on hsa-miR-21-5p and MMP9 has not been evaluated in T2DM and DN patients. The study subjects were divided into three groups (Healthy controls = 36, T2DM = 38, DN = 35). Anthropometric measurements were taken and biochemical tests were carried out on fasting blood samples. Reverse transcriptase PCR was employed for whole blood gene expression analysis of hsa-miR-21-5p and MMP9. Bioinformatics analyses including drug-gene interaction, protein-protein interaction, functional enrichment analyses and co-expression networks were performed. In the present study, MMP9 and hsa-miR-21-5p levels were downregulated and upregulated respectively in T2DM and DN patients when compared with healthy controls. However, in metformin-treated group, a downregulation of hsa-miR-21-5p and upregulation of MMP9 was observed. In-silico analysis revealed the target genes involved in the miR-21 and MMP9 interaction network. Metformin directly targets miR-21 and regulates MMP9 expression in T2DM patients, influencing the pathogenesis of DN.HighlightsMMP-9 and hsa-miR-21-5p were downregulated and upregulated respectively in T2DM and DN patients in a Western Indian population.The patients treated with metformin showed downregulation of hsa-miR-21-5p and upregulation of MMP9.In-silico analysis revealed MMP-9 as well as PTEN to be targets of hsa-miR-21-5p.Metformin regulates MMP9 expression in T2DM and DN patient populations through hsa-miR-21-5p.

Acute severe gouty arthritis secondary to isotretinoin toxicity in a young male: a case report

Acute gouty arthritis is a recognized complication of hyperuricemia and one of the most common forms of inflammatory arthritis in adults. Drug-induced hyperuricemia is increasingly prevalent in clinical practice. Diuretics, antitubercular medications, and immunosuppressants are the common drugs associated with hyperuricemia. Oral isotretinoin is the drug of choice for different forms of severe acne and is rarely associated with hyperuricemia. We present the case of a 30-year-old male with severe acne vulgaris who was prescribed isotretinoin and later presented with acute gout. The patient developed hyperuricemia and swelling of the right first metatarsophalangeal joint within two months of isotretinoin commencement. There was a second episode of similar joint swelling three months later, parallel to the isotretinoin rechallenge. The dose of isotretinoin was reduced with the addition of febuxostat. The patient did not develop further episodes and remained symptom-free without urate-lowering therapy.

361. Think Fungus! – Clinical profile, Risk factors and Diagnostic Utility of Galactomannan in diagnosis of Invasive Aspergillosis in Non-Neutropenic patients – A Prospective Study from India

Background

Invasive aspergillosis(IA) is known to occur in immunocompromised patients including neutropenic patients. But there has been a trend of increasing cases in non-neutropenic host with the emergence of newer risk factors like DM, cirrhosis etc.

The aim of this study was to evaluate the clinical features & risk factors of IA in non-neutropenic patients & to look at the clinical utility of galactomannan in diagnosis of IA.

Methods

This was a prospective observational study which included the suspected cases of IA, based on the clinical & radiological criteria. Patients with haematological & solid organ malignancy were excluded. In patients with suspected Invasive pulmonary aspergillosis (IPA), serum & BAL, while in patients with suspected CNS IA CSF & serum samples were sent for galactomannan analysis (Platelia ELISA). The clinical features, risk factors, outcomes were analysed.

Results

We screened 243 patients with suspected IA, of which 49 non-neutropenic patients with IA (16 Proven & 33 Probable cases) were included. The mean age was 47.8 years. Of all IA cases 69.5% (n=34) were IPA, 20.4% (n=10) were CNS aspergillosis & 10.2% (n=5) showed disseminated form of IA. The common symptoms included Fever (71.4%), cough (71.3%), expectoration (44.7%) & dyspnoea (59.1%) in IPA, while in CNS aspergillosis, presented with fever (73.3%), altered sensorium (53%).The predominant risk factor included previous TB, DM, COVID-19. The radiological manifestations in IPA included the typical cavity (40.4%, n=17), Centrilobular nodules with tree in bud appearance in 56.5% (n=23). The CNS aspergillosis was associated with ring enhancing lesion (41.6%, n=5) with leptomeningeal enhancement (50%, n=6), while cerebral abscess was seen in 16.6% (n=2) patients. The positivity of galactomannan were 24.4%, 91.3% & 87.5% in serum, BALF & CSF respectively. Culture positivity & Direct smear positivity was 18.3% & 28.5% respectively. The overall mortality was 20.4%. Complete response in 3 months follow-up period was seen in 69.3% patients.

Conclusion

The clinical manifestations of IA in non-neutropenic are diverse & nonspecific. Also, culture & direct microscopy lack sensitivity, hence diagnostic markers like Galactomannan can be used for early diagnosis of IA in patients with newer emerging risk factors.

Disclosures

All Authors: No reported disclosures.

340. GeneXpert Ultra for Diagnosis of Central Nervous System Tuberculosis in the High Tuberculosis Prevalence Country - A Prospective Study from India

Background

Early diagnosis and initiation of antitubercular treatment are vital steps to reducing the impact of TB in high burden countries. The molecular method like GeneXpert has significantly improved the diagnosis of TB. GeneXpert Ultra is more sensitive to the diagnosis and helps in paucibacillary samples like cerebrospinal fluid (CSF). This study aims to provide its utility in diagnosis of central nervous system tuberculosis (CNS TB) in high TB burden geography.

Methods

This prospective observational study included the suspected cases of CNS TB with age ≥12 years. Patients who presented with ≥ 5 days history of CNS symptoms suggestive of tuberculosis with a lancet score of ≥ 6 on combination of clinical, CSF and imaging criteria were included in the study. Patients diagnosed with aetiology other than tuberculosis for CNS disease were excluded. CSF was analysed for GeneXpert Ultra and mycobacterial culture. The sensitivity, specificity, positive predictive value (PPV), and Negative predictive value (NPV) of GeneXpert Ultra were analysed in comparison with culture results.

Results

A total of 107 patients with mean age of 33.2±18.5 years were analysed. CSF mycobacterial culture was positive in 45.8% (n=49) of patients. However, Mycobacterial tuberculosis via GeneXpert Ultra was detected in 57.9% (n=62) of patients. Sensitivity, specificity, PPV and NPV for GeneXpert Ultra were found 83.7%, 63.8%, 20.4% and 97.2% respectively. According to the lancet score, 70.1% (n=75) and 29.9% (n=32) of patients had probable and possible CNS TB, respectively. Among them, definitive CNS TB were diagnosed in 65.3% (n=49) and 65.6% (n=21) patients with probable and possible CNS TB, respectively.

Conclusion

GeneXpert Ultra has an excellent sensitivity and negative predictive value for the diagnosis of CNS TB in CSF samples. Even with possible CNS TB according to the lancet score, it is better to consider antitubercular treatment in a high TB burden country.

Disclosures

All Authors: No reported disclosures.

341. GeneXpert Ultra for the Diagnosis of Extrapulmonary Lymphnode Tuberculosis – A Diagnostic Study from High Tuberculosis Burden Country

Background

Extrapulmonary tuberculosis (EPTB) is quite prevalent in India, ranging from 8.3% and 13.1%. Diagnosis of EPTB is often challenging as it resembles other granulomatous conditions pathologically. TB culture remains the gold standard for definitive diagnosis, but it takes longer time and WHO has recommended the use of GeneXpert Ultra for rapid diagnosis. This study aims the utility of GeneXpert Ultra for diagnosis of tubercular adenitis.

Methods

This prospective study included the suspected tubercular adenitis patients with lymphnode size of ≥ 20mm. Patients diagnosed with other aetiology of adenitis were excluded. Excision biopsy was performed in all patients. Tissue samples were sent for Ziehl Neelson (ZN) stain, GeneXpert Ultra, histopathology and mycobacterial culture (BACTEC). The sensitivity, specificity, positive predictive value (PPV), and Negative predictive value (NPV) of GeneXpert Ultra were analysed in comparison with culture results.

Results

A total of 85 patients Lymph node were included, of which 60% (n=51) had cervical LN, 15%(n=13) abdominal LN, 12%(n=11) mediastinal LN, and 15%(n=11) others. Most of the patients (97%) HPE findings of granulomatous inflammation of which only 20%(n=17) were ZN stain Positive. TB culture showed positivity of 56.47%(n=48) . Mycobacterial tuberculosis was detected in 69%(n=59) of patients by GeneXpert Ultra & none of them showed Rifampicin resistance. The Sensitivity, specificity, PPV & NPV for GeneXpert Ultra were found 85.4%, 51.3%, 25.06% and 94.8%, respectively.

Conclusion

GeneXpert Ultra showed excellent sensitivity and negative predictive value for the diagnosis of TB Lymphadenitis. Further this method detects Rifampin sensitivity which is crucial for initiation of appropriate antitubercular drugs.

Disclosures

All Authors: No reported disclosures.

P283 A rare case of vertebral osteomyelitis caused by co-infection of Candida and Mycobacterium Tuberculosis: a double trouble

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Introduction

The vertebral osteomyelitis can be pyogenic (bacterial), non-pyogenic-granulomatous (tuberculosis, brucella, fungi), or parasitic. Fungal spondylodiscitis only accounts for 0.7%-2.7% of all spinal infections. Tubercular vertebral osteomyelitis has a high prevalence in developing countries like India. Co-infection of the spine by both fungal and tuberculous organisms is rare, there is only one case that has been reported till now in our literature review.

Case

A 62-year-old man presented with complaints of lower back pain for 3 months and fever with chills for 1 month. He had done multiple OPD visits at other centers for his lower back pain in the past 2 months, where a whole spine MRI was done which was suggestive of prolapsed intervertebral disc at multiple spinal segments- maximum at L4-L5 causing indentation of nerve roots for which he was given 3 days of IV and followed by 15 days of oral methylprednisolone. On steroids, patient developed fever and increased lower back pain for which he was admitted. Repeat MRI spine revealed features s/o axial spondylo-arthropathy. At this point, he was referred to our center for further management and was admitted. He was a known case of diabetes and underwent bilateral DJ stenting for nephrolithiasis 3 months before. On post-operative day 4, he had developed low back ache. He was vitally stable but febrile, unable to sit or walk without support. He also had tingling and numbness in bilateral lower limbs. Laboratory results showed raised inflammatory markers. Vertebral biopsy was done, CBNAAT was negative, while culture revealed growth of Candida albicans. He was started on injection of fluconazole 800 mg loading dose followed by 400 mg daily. After 5 days he got afebrile but, lower limb weakness and lower back pain persisted. Hence a repeat vertebral biopsy was planned. Surprisingly, CBNAAT of the biopsy sample detected very low MTB and indeterminate rifampicin resistance, following which the patient was initiated on weight-based HRZE regimen along with fluconazole. Currently, patient is afebrile and his lower limb weakness has improved with lower limb muscles power 0/5 to 3/5 on follow-up after a month.

Conclusion

Non-pyogenic vertebral osteomyelitis due to tuberculosis is common in a high TB burden country like India. Even though Candida is a rare causative agent, but should always be considered as a differential in patients having risk factors. In our patient abdominal surgery, DM and steroids could have predisposed for developing Candida vertebral osteomyelitis. The possibility of co-infection of TB and Candida should not be ignored in patients who have risk factors, especially if they present with clinical and radiological signs befitting its manifestations. High suspicion and tissue diagnosis remain crucial factors for early diagnosis and aids in better clinical outcomes.

P297 Disseminated histoplasmosis from skin to adrenals a cosmetic catastrophe—a rare case report

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Background

The varying presentations of histoplasmosis is always a diagnostic dilemma for clinicians. Cases of disseminated histoplasmosis can present in multiple specialties like dermatology, medicine, endocrinology, with skin, and mucosal hyperpigmentation as the only major symptom.

Case Report

Here we present a case of a 54-year-old male with hyperpigmentation all over the body with multiple specialty consultations done in the past 2 years. There was a significant history of loss of weight over a period of 2 years. His cortisol levels were low which explained the focus in the adrenals, with bilateral adrenomegaly found in imaging studies. His diagnostic work-up for TB and possible malignancy was ruled out. The provisional diagnosis of histoplasmosis was made and confirmed with biopsy and culture. Definitive treatment with antifungals was initiated, which showed improvement on follow-up.

Conclusion

Histoplasmosis is always underreported, because of a lack of information regarding the various clinical presentations. Early diagnosis and prompt treatment may save the patient from catastrophic adrenal insufficiency. The diagnosis of adrenal histoplasmosis should be considered in patients presenting with constitutional symptoms and adrenal masses with or without adrenal insufficiency. Adrenal histoplasmosis can be the only possible presentation in disseminated histoplasmosis.

P144 The uncommon meets the common: Invasive Aspergillosis and tuberculosis co-infection in non-neutropenic patients— arare association

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Background and Objective

Invasive aspergillosis (IA) is known to occur in immunocompromised patients including neutropenic patients. But, recently increasing cases have been reported in patients with non-classical risk factors and non-neutropenic patients like diabetes mellitus, chronic lung disease, HIV infection, critically ill patients, etc. According to ISHAM these non-classical risk factors should be included in EORTC/MSG host criteria for diagnosis of invasive aspergillosis.

India has a high tuberculosis (TB) burden, and this is always considered as the first differential for any patient with fever, cough, hemoptysis, and weight loss. Post-tubercular chronic pulmonary aspergillosis common reported condition. However, co-infection of active TB and invasive aspergillosis is less reported. This co-infection could be one of the contributors of high morbidity and mortality in cases with tuberculosis.

We hereby present a series of five cases of TB concomitant with invasive aspergillosis in non-neutropenic patients.

Methods

This is a prospective observational study, all patients admitted with molecular diagnosis (GeneXpert) of tuberculosis and with at least one non-classical risk factor for invasive aspergillosis were subjected to further evaluation. Diagnosis of invasive aspergillosis was considered in patients who had at least one clinical and one mycological EORTC criteria. Galactomannan level in different samples was measured via Platelia^TM ELISA. The efficacy of different antifungals and outcomes were analyzed.

Results

Total 57 patients with TB underwent for evaluation of invasive aspergillosis. Among them, five patients were diagnosed to have concomitant TB and invasive aspergillosis, of which three cases of CNS TB and CNS aspergillosis and two had concomitant pulmonary infections. The average age was 31 ± 12 years with a female preponderance (4/5). Two patients were HIV positive, while among non-HIV patients, one had CD4 cytopenia (CD4-171). One patient had no known predisposing factor. Radiologically, most common pulmonary lesions were patchy consolidation with centrilobular nodules with tree in bud appearance, while CNS lesions showed multiple ring-enhancing lesions. All the patients had CBNAAT positive, two from BAL sample, 1 from CSF, and 1 from the lymph node. Rifampicin was sensitive in all, except one who had rifampicin resistance indeterminate. Of these patients, four were probable invasive aspergillosis satisfying the host, mycological and clinical factors as per the EORTC/MSGERC 2021 guidelines. The treatment of coinfection is challenging due to the interaction of rifampicin with voriconazole, which is the drug of choice for invasive aspergillosis. Here, 3 patients were treated with Inj amphotericin B, while the other 2 patients were started on voriconazole with rifampicin sparing regimen for TB. Of the 5 patients, 4 patients survived with excellent response to the treatment, with one fatality.

Conclusion

The possibility of concurrent TB and invasive aspergillosis in non-neutropenic hosts should be considered to avoid devastating outcomes. The lack of clinical suspicion may result in misdiagnosis, and most importantly, the chronicity of the infection makes it indistinguishable from TB. Moreover, the co-administration of antifungal and anti-TB medications presents significant therapeutic challenges necessitating thorough evaluation and monitoring.

P243 Case series of Cryptococcal Meningitis—Experience in North Western India over 1 year (2021–22)

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objective

Cryptococcosis is an opportunistic fungal infection causing high morbidity and mortality in patients, preferentially affecting immunocompromised. It can cause a wide array of clinical manifestation, which includes meningitis, pulmonary, as well as disseminated infection. Cryptococcus neoformans causes more than 90% cases of cryptococcal meningitis.

Methodology

We performed a retrospective review of patients with confirmed cryptococcal meningitis during 1 year period from 2021 to 2022 in tertiary care center, AIIMS Jodhpur. We assessed clinical, radiological, microbiological, and biochemical parameters along with treatment provided and outcomes of the patient.

Results

Of 189 patients screened for suspected cryptococcal meningitis, 6 were microbiologically confirmed positive. All the patients were immunocompromised, of which four were HIV positive and one was a solid organ transplant recipient on immunosuppression and one was old TB Meningitis. Most common symptom was headache and altered sensorium (100%). Radiological findings showed 30% had no significant abnormality. CSF examination revealed average CSF protein 97.6 (63-163), CSF chloride 103.3 (108-132), sugar 36.33 (1-68), with predominant lymphocytes. All the patients were microbiologically confirmed by CSF cryptococcal latex test. A total of 4/5 patients received amphotericin B (3 mg/kg) with fluconazole (1200 mg) for 2 weeks in the induction phase followed by fluconazole consolidation phase and maintenance phase. Of the five patients, four patients survive with a good response to the treatment with one fatality.

Conclusion

Through our case series we emphasize the fact that Cryptococcal meningitidis may present with non-significant radiological features. Thus, the differential diagnosis of C. meningitidis must always be thought of when an immunocompromised patient presents with headaches and other signs and symptoms involving the central nervous system.

Clinical characteristics and outcomes of digital gangrene in connective tissue disorders: a longitudinal single-centre experience from Jodhpur, India

Epidemiology, clinical presentation, and outcomes for digital gangrene in connective tissue disorders (CTD) remain underreported from tropical countries like India. In this series, we aimed to explore the clinical profile and outcomes of patients who presented with digital gangrene and a diagnosis of CTD. Hospital-based longitudinal observational study. Patients with digital gangrene and underlying diagnosis of CTD presenting to our tertiary-care centre in Jodhpur, India between1^st January 2018 and 31^st June 2021 were included. Clinical outcomes including mortality, limb outcomes, functional status and other systemic involvement were assessed. Of the 312 patients registered in the rheumatology clinic during this period, 22 (7%) patients were found to satisfy the inclusion criteria. Mean age was 46 years and 90% were females. The most common underlying diagnosis was Mixed connective tissue disorder (MCTD). Digital gangrene was the presenting symptom in 13 (60%) patients. Half of the patients received only corticosteroids as immunosuppression. Two died due to systemic complications. Complete resolution occurred in 17 (85%), autoamputation in 3, and infection requiring surgical drainage in one patient. All surviving patients reported good functional limb outcome on 6 months follow-up. MCTD is an important cause of digital gangrene in rheumatology practice. In patients presenting with digital gangrene, an active search for an underlying CTD is imperative, as this could result in timely initiation of appropriate limb-saving therapy. Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in CTD. Key Points • Mixed connective tissue disorder is an important cause of digital gangrene in rheumatology practice in western India. • In patients presenting with digital gangrene, an active search for an underlying connective tissue disorder is imperative, as this could result in timely initiation of appropriate therapy and can prove limb saving. • Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in connective tissue disorders.

Clinical and laboratory profile of patients with amoebic liver abscess

Context

Amebic liver abscess (ALA) occurs in 3%-9% of the amebiasis cases, with complications seen in 20%-40% of the cases and 2%-18% mortality rate. Successful treatment thus requires the accurate identification of these cases.

Aims and Objectives

We aimed to assess the seropositivity and profile of ALA patients in western Rajasthan.

Materials and Methods

This retrospective study was conducted at a tertiary care center in western Rajasthan from November 2017 to May 2019. Serological diagnosis of ALA was done by detecting immunoglobulin G (IgG) antibodies in the serum of the patients by ELISA. The derangements in laboratory profile (hematological and biochemical parameters) and ultrasonography findings were assessed from the hospital records. Statistical analysis was performed using Mann-Whitney U-test.

Results

Among the total cases (n = 34), 20 were diagnosed as ALA. Twenty-one (61.8%) were positive for anti-amebic IgG antibodies. Among ALA patients, 14 (70%) were >40 years old and only 6 (30%) patients were of age ≤40 years. Male: female ratio was 5.7:1, and ultrasonography records of 15 ALA patients revealed the presence of hepatomegaly (n = 7, 46.7%), pleural effusion (n = 3, 20%), lung collapse (n = 2, 13.3%), and vascular involvement (n = 1, 6.7%). The right lobe of the liver was involved in majority of the patients (n = 12, 80%). Total white blood cell count (P < 0.001), absolute neutrophil count (P = 0.001), total serum bilirubin (P = 0.019), and serum alkaline phosphatase (P = 0.018) were significantly elevated in ALA patients.

Conclusions

Seroprevalence shows that ALA still remains the dominant etiology in liver abscess patients in this region. There are significant derangements in the laboratory profile that require a larger study for corroboration.

WITHDRAWN: Pulmonary Nocardiosis Caused by Nocardia otitidiscaviarum in an Immunocompromised Patient and Its Review of Literature

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Amlodipine Induced Gum Hypertrophy - A Rare Case Report

BACKGROUND

DIGO or drug-induced gingival overgrowth occurs as a side effect of certain drugs. Until now, the etiology of drug-induced gingival overgrowth is not clearly understood. Among the calcium channel blockers, nifedipine has been shown to be most frequently associated with drug-induced gingival hyperplasia. Amlodipine is a comparatively newer calcium channel blocker that witha longer duration of action and lesser side effects as compared to nifedipine. There are only certain case reports of amlodipine-induced gum hyperplasia.

CASE PRESENTATION

We report a case of amlodipine-induced gum hyperplasia in a 66-year-old hypertensive patient taking amlodipine at a dose of 5 mg once a day. There was significant regression of gum hypertrophy after substitution of amlodipine by Losartan.

CONCLUSION

Amlodipine is one of the commonly prescribed antihypertensive drugs, and gingival hyperplasia is one overlooked side effect in patients taking amlodipine. Awareness of this potential side effect of amlodipine may be helpful to reduce the anxiety of patients and the cost of diagnostic procedures.

Clinical features and mortality in COVID-19 SARI versus non COVID-19 SARI cases from Western Rajasthan, India

Background:

In March 2020, the Indian Council of Medical Research (ICMR) issued guidelines that all patients presenting with severe acute respiratory infections (SARI) should be investigated for coronavirus disease 2019 (COVID-19). Following the same protocol, in our institute, all patients with SARI were transferred to the COVID-19 suspect intensive care unit (ICU) and investigated for COVID-19.

Methods:

This study was planned to examine the demographical, clinical features, and outcomes of the first 500 suspected patients of COVID-19 with SARI admitted in the COVID-19 suspect ICU at a tertiary care center. Between March 7 and July 20, 2020, 500 patients were admitted to the COVID-19 suspect ICU. We analyzed the demographical, clinical features, and outcomes between COVID-19 positive and negative SARI cases. The records of all the patients were reviewed until July 31, 2020.

Results:

Of the 500 suspected patients admitted to the hospital, 88 patients showed positive results for COVID-19 by reverse transcription-polymerase chain reaction (RT-PCR) of the nasopharyngeal swabs. The mean age in the positive group was higher (55.31 ± 16.16 years) than in the negative group (40.46 ± 17.49 years) (P < 0.001). Forty-seven (53.4%) of these patients in the COVID-19 positive group and 217 (52.7%) from the negative group suffered from previously known comorbidities. The common symptoms included fever, cough, sore throat, and dyspnea. Eighty-five (20.6%) patients died in the COVID-19 negative group, and 30 (34.1%) died in the COVID-19 positive group (P = 0.006). Deaths among the COVID-19 positive group had a significantly higher age than deaths in the COVID-19 negative group (P < 0.001). Among the patients who died with positive COVID-19 status had substantially higher neutrophilia and lymphopenia (P < 0.001). X-ray chest abnormalities were almost three times more likely in COVID-19 deaths (P < 0.001).

Conclusion:

In the present article, 17.6% of SARI were due to COVID-19 infection with significantly higher mortality (34.1%) in COVID-19 positive patients with SARI. Although all patients presenting as SARI have considerable mortality rates, the COVID-19-associated SARI cases thus had an almost one-third risk of mortality.

Progressive disseminated histoplasmosis in idiopathic CD4 lymphocytopenia an underdiagnosed combination - a case report

Progressive disseminated histoplasmosis (PDH) usually presents as fever, anemia, leukopenia, hepatosplenomegaly, lymphadenopathy and pulmonary symptoms. There are few reports on the association of idiopathic CD4 lymphocytopenia (ICL) with histoplasmosis. We describe a 65-year-old female presented with a history of fever, papulo-nodular rash and significant weight loss and diagnosed as progressive disseminated histoplasmosis. All immunocompromised conditions were ruled out. In addition, her 2 consecutive CD4 counts were below 300. The patient was diagnosed with PDH associated with ICL. The patient showed significant improvement with liposomal amphotericin B and itraconazole. Absolute CD4 counts should be done in all cases of progressive disseminated histoplasmosis even in HIV negative individuals to rule out associated ICL.

Predictors of Clinical Outcomes in Adult COVID-19 Patients Admitted to a Tertiary Care Hospital in India: an analytical cross-sectional study

BACKGROUND

The outbreak ofsevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted inexponential rise in the number of patients getting hospitalised with corona virus disease 2019 (COVID-19). There is a paucity of data from South East Asian Region related to the predictors of clinical outcomes in these patients. This formed the basis of conducting our study.

METHODS

This was an analytical cross-sectional study. Demographic, clinical, radiological and laboratory data of 125 patients was collected on admission. The study outcome was death or discharge after recovery. For univariate analysis, unpaired t-test, Chi-square and Fisher's Exact test were used. Receiver operating characteristic (ROC) curves were plotted for Sequential Organ Failure Assessment (SOFA) score and few laboratory parameters. Logistic regression was applied for multivariate analysis.

RESULTS

Elderly age, ischemic heart disease and smoking were significantly associated with mortality. Elevated levels of D-dimer and lactate dehydrogenase (LDH) and reduced lymphocyte counts were the predictors of mortality. The ROCs for SOFA score curve showed a cut-off value ≥ 3.5 (sensitivity- 91.7% and specificity- 87.5%), for IL-6 the cut-off value was ≥ 37.9 (sensitivity- 96% and specificity- 78%) and for lymphocyte counts, a cut off was calculated to be less than and equal to 1.46 x 109per litre (sensitivity-75.2%and specificity- 83.3%).

CONCLUSION

Old age, smoking history, ischemic heart disease and laboratory parameters including elevated D-dimer, raised LDH and low lymphocyte counts at baseline are associated with COVID-19 mortality. A higher SOFA score at admission is a poor prognosticator in COVID-19 patients.

Clinical characteristic, red blood cell indices, iron profile and prognosis of heart failure in females

Background: Heart failure is a leading killer worldwide, with concurrent anaemia and iron deficiency portending sepulchral prognosis. Anaemia is rampant, with 53% prevalence in Indian females, but iron deficiency can be present even without anaemia. Therefore, this study was planned to determine the clinical profile, red blood cell indices, and effects of iron deficiency, on the course and prognosis of heart failure in Indian females.

Materials and methods: This was a hospital-based observational study, conducted at a tertiary care teaching institute in India. Data from 147 females enrolled in the study between September 2017 to March 2020 was collected out of all patients enrolled in ongoing heart failure registry at the institute. Clinical characteristics at presentation, iron profile, red blood cell indices, treatment and mortality data was collected.

Results: Mean age of the subjects (n = 147) was 53.31 ± 17.1 years with 55% non-rheumatic and 45% with rheumatic heart disease. The patients with rheumatic heart disease were younger, with a higher prevalence of atrial fibrillation. Non-rheumatic patients had a higher prevalence of CV risk factors like diabetes, hypertension, renal failure, more patients in NYHA IV, and 83% patients had LVEF ≤40%. Anaemia was present in 49%, however iron deficiency was present in 89% (absolute iron deficiency in 80% and functional iron deficiency in 9%) with no significant difference between rheumatic and non-rheumatic group. Red blood cell indices showed no significant difference across the spectrum of iron deficiency and anaemia, except lower mean corpuscular volume in patients with both iron deficiency and anaemia. The mean survival time was 840 days, with no significant difference between groups. There was significantly higher mortality in patients with iron deficiency (log rank 0.045).

Conclusion: Iron deficiency–with or without anaemia–is very high in Indian females, worsening survival in heart failure. Proper diagnosis with iron supplementation will improve the prognosis.

Clinical profile and outcome of patients with Crimean Congo haemorrhagic fever: a hospital based observational study from Rajasthan, India

BACKGROUND

Crimean Congo haemorrhagic fever (CCHF) is an emerging zoonotic infection with high mortality. Nosocomial spread is described secondary to body fluid contact.

METHODS

Patients meeting the case definition for viral haemorrhagic fever (VHF) from August to November 2019 were tested for CCHF after ruling out dengue, malaria, scrub typhus and leptospirosis in a tertiary teaching hospital in western Rajasthan, India. Diagnosis was confirmed using both quantitative reverse transcription polymerase chain reaction and immunoglobulin M/immunoglobulin G enzyme-linked immunosorbent assay for all patients. All hospital contacts were line listed and tested and symptomatic high-risk contacts received ribavirin post-exposure prophylaxis. Cohorting, personal protective equipment use and hand washing were employed to prevent nosocomial spread.

RESULTS

Four patients tested positive for CCHF. We encountered uncommon initial presentations involving motor weakness and supraventricular tachycardia. Elevated serum lactate dehydrogenase and creatinine kinase were useful in clinical diagnosis. Only one patient survived despite ribavirin therapy. There was zero nosocomial transmission. A partial segment of nucleocapsid of amplified CCHF virus was 99.62% identical to the Afghanistan and Oman strains.

CONCLUSIONS

The distribution of CCHF appears to be expanding, with CCHF emerging as endemic in Rajasthan, India. In this setting of high mortality, hand washing and PPE use prevented nosocomial transmission.

Role of interleukin-2 and interleukin-18 in newly diagnosed type 2 diabetes mellitus

OBJECTIVES

The study aimed to compare the levels of anti-inflammatory interleukin-2 (IL-2) and proinflammatory interleukin-18 (IL-18) among newly diagnosed type 2 diabetes mellitus (T2DM) and nondiabetic volunteers, to predict their roles as markers in the diagnosis of newly diagnosed T2DM.

METHODS

In the study, 60 subjects were enrolled (30 T2DM cases and 30 non-diabetic controls). Biochemical parameters such as fasting plasma glucose (FBS), glycated haemoglobin (HbA_1c), high sensitivity C-reactive protein (hs-CRP) and lipid profile were estimated in auto-analyser. Serum IL-2 and IL-18 levels were assessed by enzyme-linked immune sorbent assay (ELISA).

RESULTS

Significant differences were observed in the levels of interleukins among study groups. The median (95% confidence interval) of IL-2 in cases and controls were 8.55 (6.07-47.23) and 45.87 (12.81-145.4) (p=0.02). The median (95% CI) of IL-18 on the other hand in cases and controls were 691.6 (580.3-872.6) and 511.1 (452.6-557.5) (p=0.0014).

CONCLUSIONS

Our study is the first to correlate IL-2 and IL-18 in newly diagnosed T2DM patients. Findings from this study highlight the anti-inflammatory role of IL-2 and proinflammatory role of IL-18 in T2DM. ROC analysis helped predict their role as markers in T2DM diagnosis.

Hemorrhagic manifestation in different etiologies of pancytopenia: A prospective, cross-sectional study

Background

Pancytopenia is a triage of anemia, leukopenia, and thrombocytopenia. The etiology causing pancytopenia varies depending upon factors such as age, sex, occupation, and geographical distribution. Unfortunately, the major treatises of hematology have not given emphasis on the hemorrhagic manifestation of different etiologies causing pancytopenia.

Objective

This observational study was carried out with the aim to identify hemorrhagic manifestation in patients with pancytopenia in eastern India.

Design

This study was conducted over a period of two years at the Department of Medicine of a tertiary care teaching institute in eastern India. All the patients with features of anemia, thrombocytopenia, or leukopenia were screened for pancytopenia and a total of 214 cases were selected. Patients were divided into two groups as patients with age more than 14 years constitute group one and the patients less than 14 years constitute the second group. A detailed physical examination, hematological, and biochemical investigation was done to ascertain the hemorrhagic manifestations in pancytopenia patients.

Results

In the groups, the most common cause of hemorrhagic manifestation in patients with pancytopenia was aplastic anemic, leukemia, myelodysplastic syndrome, and myelofibrosis. No bleeding manifestation was seen in patients with megaloblastic anemia, kala-azar, hypersplenism, and other causes of pancytopenia.

Conclusions

Patients with pancytopenia caused by aplastic anemia, acute leukemia, and myelodysplastic syndrome have more chances of bleeding manifestation as compared with pancytopenia caused by megaloblastic anemia, kala-azar, or hypersplenism.

Thrombocytopenia in malaria patients from an arid region of Western Rajasthan (India)

Context

The arid climate of Western Rajasthan is challenging for malaria transmission, with the number of cases correlating directly with the annual rainfall pattern. Moreover, >90% of the cases in this region are caused by Plasmodium vivax, which has recently been shown to cause a similar degree of thrombocytopenia as Plasmodium falciparum.

Aims and Objectives

The aim of the study was to determine the degree of thrombocytopenia in malaria patients and its association with different species of malaria in this region with an unstable malaria epidemiology.

Materials and Methods

This retrospective study was conducted on all microbiologically confirmed malaria patients with documented platelet counts from August 2017 to October 2018. Microbiological diagnosis was established by rapid diagnostic tests and peripheral blood film examination. Platelet counts were used to assess the degree of thrombocytopenia.

Results

A total of 130 cases were included in the study, of which 118 (91%) were caused by P. vivax, while the rest 12 (9%) were caused by P. falciparum. Thrombocytopenia was present in 108 (83%) cases, and the mean values of platelets in thrombocytopenic patients with P. vivax and P. falciparum infection were 72600/μL and 48500/μL, respectively. Although P. falciparum infection was significantly associated with severe thrombocytopenia (odds ratio: 4.7, [95% confidence interval 1.3-16.1]), extremely low platelet counts (n = 5) warranting platelet transfusions (n = 1) were seen only in P. vivax cases. Only one patient required platelet transfusions in these patients suggesting good tolerance to thrombocytopenia.

Conclusions

Avoiding unnecessary transfusions in febrile thrombocytopenic patients with an established malaria diagnosis can help in reducing transfusion-transmitted infections.

Clinical outcome, viral response and safety profile of chloroquine in COVID-19 patients - initial experience

INTRODUCTION

Chloroquine and its analogues are currently being investigated for the treatment and post exposure prophylaxis of COVID-19 due to its antiviral activity and immunomodulatory activity.

MATERIAL AND METHODS

Confirmed symptomatic cases of COVID-19 were included in the study. Patients were supposed to receive chloroquine (CQ) 500 mg twice daily for 7 days. Due to a change in institutional protocol, initial patients received chloroquine and subsequent patients who did not receive chloroquine served as negative controls. Clinical effectiveness was determined in terms of timing of symptom resolution and conversion rate of reverse transcriptase polymerase chain reaction (RT-PCR) on day 14 and day 15 of admission.

RESULTS

Twelve COVID-19 patients formed the treatment arm and 17 patients were included in the control arm. The duration of symptoms among the CQ treated group (6.3 ± 2.7 days) was significantly (p-value = 0.009) lower than that of the control group (8.9 ± 2.2 days). There was no significant difference in the rate of RT-PCR negativity in both groups. 2 patients out of 12 developed diarrhea in the CQ therapy arm.

CONCLUSION

The duration of symptoms among the treated group (with chloroquine) was significantly lower than that of the control group. RT-PCR conversion was not significantly different between the 2 groups.

Mycobacterium chelonae bacteraemia in a patient with myasthenia gravis receiving long-term steroid therapy

Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms found in soil and water. Infections caused by NTM are increasing with conditions ranging from harmless colonization to invasive infections, the latter being more common in immunocompromised hosts. In this report, we present a case of bacteraemia caused by Mycobacterium chelonae, a rapidly growing NTM belonging to Class IV in the Runyon classification, in a 71-year-old male with ocular myasthenia gravis undergoing treatment with oral prednisolone. Gram staining of these organisms from blood culture can be easily overlooked or confused with diptheroids. Detection of Gram-positive bacilli should prompt Ziehl–Neelsen staining to distinguish diphtheroids from rapidly growing mycobacteria in immunosuppressed patients. In addition, speciation and antimicrobial susceptibility testing are of paramount importance in such cases as there is considerable variation in the resistance patterns between different species of NTM. Line probe assay provides a rapid and reliable method for identification of NTM to the species level, which can guide treatment with appropriate antibiotics. This case report highlights the importance of early detection of such cases so as to optimize management and improve patient outcomes.

Diagnosis and Management of Cryptogenic Occupational Tetanus: A Case Report from Rajasthan, India

The reported cases of non-neonatal tetanus have doubled from 2015 to 2017 in India, while neonatal tetanus has declined by half during this period. Most of these non- neonatal tetanus are acquired by occupational exposure especially in high risk populations such as agricultural workers, industrial workers and health care workers secondary to increased spore exposure or risk for minor injuries. We report a case of occupational tetanus in a steel worker and discuss the importance of recognising tetanus as an occupational hazard and address issues related to its early diagnosis and management. The report also highlights the need for policymakers and health practitioners in India to evolve a robust understanding of the needs and vulnerabilities of high risk occupational groups in order to apply specific and effective interventions to prevent occupational tetanus.

Disseminated histoplasmosis in immunocompetent patients from an arid zone in Western India: A case series

Histoplasmosis is a systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum and is more common in immunocompromised patients. We report two cases of disseminated histoplasmosis in immunocompetent individuals from a non-endemic zone in Western India. Rapid diagnostic tests like urinary antigen detection and molecular assays comprise the need of the hour as early initiation of antifungal therapy can be life-saving. Clinicians need to be aware of this entity to prevent misdiagnosis and initiate prompt effective management.

Celiac disease with Budd-Chiari syndrome: A rare association

Budd-Chiari syndrome is characterized by hepatic venous outflow tract obstruction. We describe an 18-year-old female of known celiac disease presented with progressive abdomen distention and shortness of breath for the last 1 month. Computed tomography of abdomen revealed hepatic vein obstruction. The patient was diagnosed with Budd-Chiari syndrome. Coagulation profile showed an increased homocysteine level. Serum folate level was also decreased. The patient was put on oral anticoagulant with a gluten-free diet. After 4 weeks, the patient showed significant improvement with decreased ascites. The association of Budd-Chiari syndrome with Celiac disease has not yet been fully understood. There have been few reports that described this rare association. Budd-Chiari syndrome should be considered as an important differential in a patient with unexplained ascites and celiac disease.

Cardiac arrest in a case of systemic lupus erythematosus and hepatitis-B coinfection: Can Strongyloides stercoralis be the culprit?

Strongyloides stercoralis is one of the most important helminths causing neglected tropical diseases. Its ability to cause autoinfection can lead to chronic infections and hyper infection, especially in autoimmune cases and prove to be highly fatal. We report a case of systemic lupus erythematosus (SLE) having hepatitis-B coinfection, who presented with rash all over the body, recurrent nausea, vomiting, cough, loose stool, and joint pain for 1 month and was later on found to be infected with S. stercoralis. He suffered a massive cardiac arrest during his hospital stay, which was efficiently managed. S. stercoralis infection in cases of SLE and other immunocompromised conditions must be treated at the earliest, to prevent fatal cardiac arrests and other complications.

Prediction of Cardiovascular Disease Risk Using Framingham and Data on Adverse Effect of Antiretroviral Drugs Risk Equation in Relation to Lipodystrophy in HIV Patients on Highly Active Antiretroviral Therapy

Background:

In the era of high active antiretroviral therapy (HAART), with increasing survival of HIV patients, cardiovascular risk has emerged as a leading health issue.

Aims:

This study aims to predict the 10-year cardiovascular disease risk in HIV patients using the Framingham risk score and its modification for HIV-infected patients on HAART, that is, the data on adverse effect of antiretroviral drugs (DAD) prediction equation.

Setting and Design:

This is a case control study.

Materials and Methods:

The present study included 320 subjects (220 HIV infected cases and 100 age, sex and body mass index matched HIV noninfected healthy controls) and was conducted in a tertiary care centre in western Rajasthan. All the patients were subjected to a detailed clinical history, complete physical examination and evaluation of laboratory parameters. We calculated Framingham risk score and DAD prediction equation for these patients and compared these scores between patients on HAART with lipodystrophy, those without lipodystrophy, HAART naive and healthy controls.

Statistical Analysis:

Unpaired t-test was used and statistical analysis was performed using SPSS version 20.

Results:

In our study, 46.67% patients on HAART developed lipodystrophy, of which 17.72% had moderate-to-high risk of cardiovascular risk according to Framingham risk score, which is significantly higher than in patients without lipodystrophy and controls (3.3% and 6%, respectively). Similar high risk was also seen with DAD score. The various risk factors also showed a positive correlation with duration of HAART.

Conclusion:

Our study emphasizes the need for early recognition of cardiovascular risk in HIV-infected patients on HAART, especially in those with lipodystrophy and advocates effective use of risk calculators in these patients.