Early Versus Late Endotracheal Intubation in Subjects with COVID-19 Pneumonia Treated with High-Flow Oxygen: A Retrospective Observational Study

INTRODUCTION

The availability of high-flow oxygen (HFO) machines allowed patients with COVID-19 pneumonia to be comfortably treated for longer periods of time until endotracheal intubation became inevitable. Patients treated with invasive mechanical ventilation (MV) preceded by HFO treatment may continue to progress and die. Hence there is a belief in physicians that patients treated with HFO might have delayed invasive MV.

METHODS

The study was conducted as a retrospective review of subjects with confirmed COVID-19 admitted to the Dubai Hospital ICU. Study variables included time to intubation, duration of HFO, and cumulative duration of tachypnea and tachycardia while on HFO usage. Early intubation was defined as within 24 hours of the start of HFO, and late intubation was defined as after seven days on HFO. Groups were compared for outcome measures; mortality and length of stay (LOS) in the ICU and hospital.

RESULTS

Clinical outcomes of mortality and LOS in ICU and hospital were not significantly different among patients intubated early versus late. Duration of tachypnea and tachycardia was also not different comparing patients intubated early versus late.

CONCLUSION

There was no significant difference in clinical outcomes in patients intubated early versus late in patients treated with HFO for COVID-19 pneumonia.

Procalcitonin Testing With Secondary Coinfection in Patients With COVID-19

Background

The coronavirus disease (COVID-19) virus has caused millions of deaths. It is difficult to differentiate between pure viral COVID-19 pneumonia and secondary infection. Clinicians often use procalcitonin (PCT) to decide on empiric antibiotic therapy.

Methodology

We performed a retrospective study of patients admitted with COVID-19 between January 1st, 2020, and June 30th, 2020. Patient demographics, clinical findings, and laboratory findings with a focus on PCT levels were recorded. Coinfection was considered if clinicians ordered a septic workup (urine, blood, and respiratory cultures) or if the physicians started or escalated antimicrobial therapy. PCT levels on the day of culture and daily for the next three days were recorded. Significant PCT change was defined as a decrease in PCT levels of >50% from the initial elevated PCT level.

Results

In total, 143 (59.8%) patients had one secondary infection. These included pulmonary infections (118, 49.4%), blood infections (99, 41.4%), and urine infections (64, 26.8%). Many patients had more than one documented positive culture: respiratory system and blood together in 80 (33.4%) patients, sputum and urine in 55 (23.1%) patients, and urine and blood in 46 (19.2%) patients. Out of the 143 patients with a positive culture, PCT was abnormal on the day of positive culture in 93 (65.5%), while PCT was abnormal in 64 out of 96 on the day of negative culture (66.7%) (p = 0.89). Individual analysis for PCT levels of respiratory cultures showed out of 118 positive sputum cultures, 86 (72%) had abnormal PCT on the day of culture. PCT in positive versus negative cultures was not significantly different, with median PCT (interquartile range, IQR) of 1.66 (6.61) versus 1.03 (2.23) (p = 0.172). For blood cultures, out of 99 positive blood cultures, 73 (73%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was significantly elevated, with a median of 1.61 (5.97) vs. 0.65 (1.77) (p < 0.001). For urine, out of 64 positive cultures, 41 (64.1%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was not significantly different, with a median of 0.71 (2.92) vs. 0.93 (4.71) (p = 0.551). To observe the change in PCT after culture, PCT values for the next three days after culture were analyzed. We found that patients with positive cultures had higher PCT levels than those with negative cultures. There was no significant improvement over the following three days. Patients with abnormal PCT on the day of the suspected infection had a longer length of stay in the hospital, with a median (IQR) of 23.9 days (3.16) vs. 16.9 days (2.18) (p = 0.021).

Conclusions

Secondary coinfections in patients with COVID-19 infections are not associated with PCT elevation on the day of suspected secondary infection. However, most patients with bacteremia had a significant elevation of PCT on the day of bacteremia before collection and reporting of positive culture. Patients with abnormal PCT levels on the day of suspected infection had a longer hospital stay than patients with normal PCT levels. Subsequent testing of PCT in patients showed no significant improvement in PCT.

Clinical Profile of Mortality and Treatment Profile of Survival in Patients with COVID-19 Pneumonia Admitted to Dubai Hospital

<b><i>Background:</i></b> Most COVID-19 studies conclude old age and coexisting illnesses as mortality determinants owing to different populations or methodologies, or omitting factors affecting outcomes. <b><i>Methods:</i></b> We analyzed COVID-19 patients’ data (<i>N</i> = 391) of Dubai Hospital between January 1, 2020 and June 30, 2020. <b><i>Results:</i></b> Only 19 patients (4.8%) were UAE nationals, while 372 (95.2%) were expatriates. Median age was 48 (interquartile range, 40–56) years; 22% were &#x3c;40 years, and only 16.6% were female. Cough was the most common symptom (78.7%), fever was 77.4%, and gastrointestinal symptoms were least common (13.8%). Approximately 95% had elevated C-reactive protein (CRP) and D-dimers (79%), lymphocytopenia 47.3%, and thrombocytopenia 13.8%. Mortality was 30% for the total sample and 50% in ICU patients. ICU patients were older than non-ICU (age; 49.6 ± 10.9 vs. 46.7 ± 12.7 years, <i>p</i> = 0.04). Eighty-five percent of ICU patients required invasive mechanical ventilation, 78% vasopressors, 88% sedation, 84% muscle paralysis, while none require any of these in the medical group. Survivors had fewer patients with sedatives (<i>p</i> = 0.01). The median length of stay in the hospital was 19 days, ICU stays 14 days, and ventilator 11 days. The Mann-Whitney test showed that survivors spent more days in the ICU (median [IQR] 18 [6.5–29.5] vs. 11 [4–18], <i>p</i> value 0.003) and the hospital (32 [14.5–49.5] vs. 14 [7–21], <i>p</i> value 0.001) than nonsurvivors. Ferritin and D-dimers were higher in nonsurvivors, but CRP was lower in nonsurvivors (ferritin (ng/mL) median (IQR) 1,434 (661.5–2206.5) versus 1,362 (630–2,094), <i>p</i> value = 0.017, CRP (mg/L) 118.7 (53.4–184) versus 134.9 (66.5–203.2), <i>p</i> value 0.001 and D-dimer (µg/mL) 1.54 (0–3.13) versus 1.09 (0–2.51), <i>p</i> value = 0.001). Multiple logistic regression analysis determined age, fever on admission, use of oxygen, mechanical ventilation, and steroids as predictors of survival. <b><i>Conclusions:</i></b> COVID-19 patients were young males with pre-existing conditions. Ferritin, CRP, and D-dimers were higher in nonsurvivors. Treatment with chloroquine, antivirals, and anticoagulation was not different between survivors and nonsurvivors. Steroid use was a survival predictor.

Crimean-Congo haemorrhagic fever presenting with acute compartment syndrome of the extremities (think beyond normal infections)

Crimean-Congo haemorrhagic fever (CCHF) is a viral zoonosis transmitted to humans and animals (which act as a reservoir) through the bite of a 'Hyalomma' tick. CCHF virus belongs to the genus Nairovirus Humans are infected when they come in direct contact with the blood or secretions of infected livestock or other infected humans. This disease initially presents with non-specific febrile symptoms common to many viral illnesses and later progresses to disseminated intravascular coagulation (DIC) with haemorrhagic manifestations.We present the case of a middle-aged man with CCHF. He presented to the hospital with DIC and acute compartment syndrome in the right forearm, requiring urgent orthopaedic intervention. The diagnosis was delayed because there was no clear history of contact. The patient was started taking ribavirin on the fifth day of hospital admission. He recovered fully.

Falciparum Malaria Presenting With Tetany: Endocrinopathies Associated With Falciparum Malaria

Malaria is a common public health problem which may have high morbidity and mortality. Physicians should be aware of the unusual presentations of this disease so that it can be timely diagnosed and treated. Herein we are presenting a case of falciparum malaria who presented to the hospital with carpopedal spasm and tetany. We will subsequently discuss mineral homeostasis and the mechanisms of hypocalcaemia in falciparum malaria and the dysregulation of calcium, phosphorus and magnesium metabolism.

Malignant Hypertension Complicated By Renal Thrombotic Micro Angiopathy: Role Of Adam 13 Mutational Analyses

We report a case of a 38-year-old U.A.E national who presented with malignant hypertension and features of thrombotic microangiopathy. He presented with oliguria, renal failure, thrombocytopenia and haemolytic anaemia. He required several sessions of renal replacement therapy. ADAM 13 mutational analysis was sent to differentiate Thrombotic micro angiopathy due to thrombotic thrombocytopenic purpura (TTP) or malignant hypertension. Renal biopsy revealed histopathological features of malignant arteriolar nephrosclerosis (MANS). Haemolytic parameters improved after control of blood pressure and he was subsequently discharged with early nephrology follow up.

Primary Empty Sella Syndrome Presenting With Severe Hyponatremia And Minimal Salt Wasting

A 41 year old Jordanian gentleman known case of osteogenesis imperfecta presented with vomiting, decreased oral intake followed by confusion. At presentation he was found to have signs of hypogonadism with severe hyponatremia. The hyponatremia responded to intravenous steroid replacement .This alerted the physicians to search for other pituitary hormone deficiencies. Our patient had pneumonia with respiratory failure. He was intubated and mechanically ventilated. Subsequent tracheostomy was done because of failure of weaning. His GCS remained very low despite treatment of infection and correction of electrolyte imbalance. He had multiple hormone deficiencies. He was found to be severely hypothyroid, replacement of thyroxine caused gradual improvement of GCS over a period of six to eight weeks. In the absence of history pituitary adenoma, pituitary, irradiation or surgery, a diagnosis of primary empty Sella syndrome with anterior pituitary dysfunction was made.

COMMUNITY ACQUIRED METHICILLIN SENSITIVE STAPHYLOCCUS AUREUS CEREBRAL ABSCESS IN A PREVIOUSLY HEALTH GENTLEMAN MIMICKING SIGNS OF CAVERNOUS SINUS THROMBOSIS-A UNIQUE PRESENTATION

Central Nervous System (CNS) infections like meningitis and cerebral abscess caused by Staphylococcus aureus are usually seen in patients with neurosurgical interventions or immune compromised patients or patients with cardiac vegetation's. They are extremely rare in healthy patients. We report a case of a 44 year old Indian gentleman who was perfectly healthy with no known co morbidities, which presented with fever, neck stiffness and altered mental status. He had fulminant staph bacteraemia (as evidenced by persistently positive blood cultures) with meningitis and cerebral abscess. Extensive search was made to find the source of infection, but it was inconclusive. Isolated CNS Methicillin Sensitive Staphylococcus aureus (MSSA) infection in an apparently healthy patient is very rare. This gentleman presented with altered mental status, asymmetrical exophthalmos and multiple cranial nerve palsies. This case highlights the challenge of making early diagnoses of a brain abscess; since it has symptomology mimicking cavernous sinus thrombosis .This is due to the involvement of the cerebellopontine angle and extensive brain oedema and oedema of the retro bulbar tissues.

Exenatide induced acute kidney injury

Exenatide is an incretin mimetic. It was approved by the federal drug authority in 2005 for the treatment of type-2 diabetes. Since it is a relatively new medicine clinicians have limited experience with regards to its side effects and safety profile. We report a 47 year old lady who presented with exenatide associated acute kidney injury. She had type-2 diabetes for 10 years with mild micro albuminuria and normal renal functions. She was also taking a stable dose of metformin, gliclazide, angiotensin converting enzyme inhibitor and diuretic for over a year and there was no history of any recent use of non-steroid anti-inflammatory medications. One week after starting exenatide, she developed severe vomiting, followed by hypotension. She presented with acute renal insufficiency and severe lactic acidosis and had to be dialyzed on emergency basis. To our knowledge this is probably the first case reported in the local United Arab Emirate (U.A.E) population.

Linezolid induced black hairy tongue: a rare side effect

Linezolid induced black hairy tongue is a rare benign reversible side effect of linezolid therapy. We report a case of a 61 year old diabetic lady who developed thrombocytopenia and black hairy discoloration of the tongue after being prescribed linezolid for foot osteomyelitis by the orthopaedic surgeon. Patient was encouraged to practice good oral dental hygiene, advised to use a soft tooth brush, regular mouth wash and baking soda containing tooth paste. The condition resolved four weeks after cessation of the antibiotic therapy.

Renin angiotensin aldosterone system in the cardiovascular continuum: An overview of the trial evidence and clinical practice

The renin angiotensin aldosterone system (RAAS) inhibitors represent an invaluable class of drugs in the management of various stages of the cardiovascular disease continuum. Both angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have unique pharmacodynamics properties. These enable them to block the RAAS system at multiple levels. The ARBs inhibit RAAS in a mechanistically distinct fashion when compared to the ACEIs. Whereas ACEIs decrease the synthesis of angiotensin II, ARBs selectively and competitively bind to the AT1 receptors hence preventing there activation by angiotensin II. The differential effects of these two groups of drugs, resulted in them playing different roles in primary and secondary cardiovascular protection. It is suggested that ACEIs tend to be more “cardioprotective” whereas ARBs may be more “cerebral-protective”.

In this review article, we will attempt to enhance understanding of the role of RAAS blockers in most appropriate selection of ACEIs and ARBs according to their attributes and the needs of the clinical situation. We will initially described the role of RAAS activation in the pathophysiology of common cardiovascular disease processes. This will be followed by a review of the major clinical trials of different ACEIs and ARBs in the primary prevention and secondary prevention of cardiovascular diseases.

In conclusion, the effects of ACEIs across a wide spectrum of cardiovascular diseases remain indisputable. However, ARBs showed a superior effect to ACEIs with regard to stroke, but their efficacy in certain major clinical end points seems limited.

Spectrum of hepatocellular carcinoma at Shifa International Hospital, Islamabad

BACKGROUND

The aim of this study was to review etiological and clinical features of patients with hepatocellular carcinoma (HCC) at a tertiary care centre in past nine years. Relevant data on HCC in other parts of country and world were reviewed.

METHODS

Patients who had biopsy proven HCC were reviewed retrospectively. Demographic features were noted and positivity for serology. presence of cirrhosis. level of alpha-fetoprotein, tumour size and distribution of liver lesions were noted.

RESULTS

A total of 67 patients were found to have biopsy proven HCC. Mean age was 58.64 +/- 12.77 years. Males were 79%. Hepatitis B surface antigen was noted to be positive in 23% of the patients, who were tested and hepatitis C antibody was found to be positive in 67% of the patients who were tested. Alpha fetoprotein level was 632.09 +/- 1332.31. Cirrhosis was noted in 69% patients. Tumour size in patients with single lesion was 6.6 +/- 1.14 cm. Patients with single lesion had 70% time involvement of the left lobe and 30% times had involvement of the right lobe. Fifty one percent of the patients in this series had multilocular distribution.

CONCLUSION

Hepatocellular carcinoma has become a common tumour in Pakistan and studies are showing that this cancer is related to hepatitis C virus infection in majority of the patients. A large number of them have underlying cirrhosis and are multifocal in origin and are presented in an advanced condition.