Prevalence of Maternal Cytomegalovirus Antibodies and Neonatal Congenital Cytomegalovirus at Less than 34 Weeks of Gestation: A Prospective Study

OBJECTIVE

 Congenital cytomegalovirus (cCMV) acquired postnatally can lead to hearing loss and adverse central nervous system (CNS) function, especially in the preterm neonate. We prospectively determined the prevalence of maternal serum CMV-immunoglobulin (IgG) and the incidence of cCMV at <34 weeks of gestation.

STUDY DESIGN

 Study was conducted in the United States and India. Maternal blood was collected within 5 days after delivery. CMV-IgG antibodies were quantitated by an immunoassay. Baby's urine at birth was tested for CMV-DNA by the polymerase chain reaction.

RESULTS

 In total, 65 women and 74 neonates were studied. In the United States, 6 out of 21 (76%), while in India, 42 out of 44 (96%) mothers were seropositive (combined 89%). In the United States, none of the neonates had CMV in the urine, while in India 4 out of 52 (7.7%) were positive (combined 5.4%) CONCLUSION:  Mother's blood and baby's urine should be tested for serum CMV-IgG antibodies and CMV-DNA at delivery at <34-weeks of gestational age. Targeted screening will help in making an early diagnosis of cCMV, initiate therapy, and detect and treat early CNS problems including hearing loss.

KEY POINTS

· Maternal serum CMV screening after premature delivery at less than 34 weeks of gestation.. · Neonatal urine CMV screening at less than 34 weeks of gestation.. · Prematurity: importance of CMV during premature labor and delivery at less than 34 weeks..

P168 Metastatic mo ld infections after COVID-19: the mo ld time -bomb

 

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

Objective

COVID-19-positive patients are at risk of invasive mold infection. The portal of entry is presumably the lungs, but infection may disseminate to involve other organs as described in this case series.

Patients and Methods

Patients who presented with de novo mold infection (6 proven and 1 probable) involving kidney, spine, eye, knee joint, subcutaneous tissue within 10-180 days of COVID-19 infection were included in this series (Table 1).

Conclusion

These cases suggest that metastatic infection by molds involving various organs could result from a presumed primary source in the lungs. However, the precise connection between pulmonary and metastatic infection is difficult to establish.

COVID-19 patients should be carefully followed for such metastatic mold infections which need proper diagnosis and management.

P417 Evaluation of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS)-Bruker Biotyper Sirius for identification of invasive molds

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM

 

Objectives

Susceptibility to various antifungal drugs varies between different species and subspecies within the same genus. Phenotypic identification of fungi has limitations for species-level identification. Correct identification of species and subspecies in invasive mold infections is important to initiate the appropriate antifungal therapy. Matrix Assisted Laser Desorption Ionization Time-of-Flight mass spectrometry (MALDI-TOF MS) with its proteomic analysis overcomes this limitation and helps in administering the correct anti-fungal therapy. A total of seven mold isolates from invasive fungal infections were evaluated for identification by MALDI-TOF MS and conventional morphological methods.

Methods

Total of seven isolates from invasive mold infections were identified by the conventional method of culturing specimens on Sabouraud's dextrose agar and Potato Dextrose agar with incubation at room temperature and 37°C in Biological oxygen demand (BOD) incubator. Micro-morphological identification of the fungus was done by Lacto Phenol Cotton Blue (LPCB) mount. Same isolates were processed on MALDI-TOF MS Bruker Biotyper Sirius (Bruker Daltonics, Bremen Germany) following recommended extraction protocol using ethanol absolute, acetonitrile, and 70% formic acid.

Results

As per the below Figure.

Conclusion

In four out of seven isolates phenotypic identification upto species level based on LPCB micromorphology was confirmed on MALDI-TOF MS. In the remaining three isolates we could only give a genus level identification based on LPCB mount. These three isolates were further identified upto the level of species after processing on MALDI as Aspergillus tamarii, Phaeoacremonium cinerum, and Fusarium equiseti. All mold isolates were identified with good quality mass spectra. In our experience, mold identification by MALDI-TOF MS using the Bruker Biotyper Sirius platform definitely has an edge over conventional phenotypic methods in species-level differentiation of various molds, impacting targeted antifungal management.

Once-a-Day Ceftriaxone-Amikacin Combination as Empiric Antibiotic Therapy to Enable Outpatient Management of Febrile Neutropenia in Children-16-Year Experience from a Single Institute

Shailesh KanvindeBackground  To enable outpatient department (OPD) management of febrile neutropenia (FN), we used once-a-day (OD) ceftriaxone-amikacin (CFT-AMK) as empiric antibiotic therapy. Our experience over 16-year period is presented. Methods  This was a retrospective study conducted from January2002 to December2017. Inclusion criteria were <18 years of age, undergoing cancer chemotherapy, and having FN. Exclusion criteria were FN after palliative chemotherapy, bone marrow transplantation, or at diagnosis of malignancy. Empiric CFT-AMK was used in all, except those having respiratory distress, hypotension, altered sensorium, paralytic ileus, or clinical evidence of peritonitis. Admission criteria were age <1 year, acute myeloid leukemia (AML) chemotherapy, poor performance status, need for blood transfusions, convenience, insurance, or persistent fever >48 to 72 hours after CFT-AMK. Outcomes analyzed were response (defervescence within 48-72 hours), OPD management, antibiotic upgrade, and mortality. AML diagnosis, >7 days to absolute neutrophil count >0.5 × 10 ⁹ /L, poor performance status, and malignancy not in remission were considered high-risk FN criteria. Results  CFT-AMK was given in 877/952 (92.2%) FN episodes. Seventy-six percent had hematolymphoid malignancies. Response, antibiotic upgrade, and mortality were seen in 85.7 and 65.5% ( p  < 0.0001), 15 and 45.5% ( p  < 0.0001), and 0 and 2% ( p  = 0.003) of low- and high-risk patients, respectively. Treatment was started in OPD in 52%, of which 21.6% required subsequent admission. Of those initially admitted, early discharge (hospital stay < 5 days) was possible in 24.6%. Forty-one percent episodes were managed entirely on OPD. Overall, 80% of low-risk and 42% of high-risk episodes received treatment wholly or partially on OPD. Conclusion  Our results show empiric OD CFT-AMK allows OPD management for most of the low-risk and a proportion of high-risk FN following chemotherapy in children, without compromising clinical outcomes.

The Dominance of Candida auris: A Single-center Experience of 79 Episodes of Candidemia from Western India

Introduction

Invasive candidiasis is a serious infection seen in hospitalized or immunocompromised patients. Mortality rates for candidemia can be as high as 30–60%. Candida auris is an emerging species of Candida and is increasingly becoming a global public health problem.

Methods

This was a retrospective observational study, in which we analyzed 79 episodes of candidemia. Blood cultures were done using the Bactec™ FX blood culturing instrument (Becton, Dickinson and Company Sparks, Maryland, USA). Species identification was done using VITEK® 2 YST panels (bioMérieux Inc., Durham, North Carolina, USA). Antifungal susceptibility testing was performed using VITEK® 2 AST-YSO8 panels (bioMérieux Inc., Durham, North Carolina, USA).

Results

Among the 79 episodes, the most common species was found to be C. auris (43.03% of all the episodes). Candida tropicalis was found to be the second most common species in patients admitted to our hospital with candidemia. All the isolates of C. auris were resistant to fluconazole, while 32.35 % of the isolates were also resistant to amphotericin B. Crude mortality in patients with C. auris candidemia was higher than the crude mortality for the other species.

Conclusion

This is the first study from India where C. auris was seen as the most predominant species among patients admitted with candidemia. This is a serious issue given the high rates of fluconazole resistance, mortality, and cost of therapy associated with C. auris bloodstream infections. Urgent attention needs to be diverted to infection control practices and antimicrobial stewardship programs.

How to cite this article

Prayag PS, Patwardhan S, Panchakshari S, Rajhans PA, Prayag A. The Dominance of Candida auris: A Single-center Experience of 79 Episodes of Candidemia from Western India. Indian J Crit Care Med 2022;26(5):560–563.

Prolonged Shedding of SARS-CoV-2 in Feces of COVID-19 Positive Patients: Trends in Genomic Variation in First and Second Wave

The main route of the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are through respiratory pathways and close contact of human-to-human. While information about other modes of transmission is comparatively less, some published literature supporting the likelihood of a fecal-oral mode of transmission has been accumulating. The diagnosis of SARS-COV-2 infected cases is based on the real-time reverse transcription-PCR (RT-PCR). The fecal excretion of SARS-COV-2 has been reported frequently, however, the role of fecal viral load with the severity of disease is not yet clear. Our study focused on the investigation of SARS-CoV-2 shedding in the fecal samples of patients with coronavirus disease 2019 (COVID-19). A total of 280 RT-PCR-positive patients were enrolled, among them 15.4% had gastrointestinal (GI) symptoms. It was shown that 62% of the patients were positive for SARS-CoV-2 RNA in fecal specimens. This positivity was not related to the presence of GI symptoms and the severity of disease. The next generation sequencing [NGS] of SARS-CoV-2 from fecal samples of patients was performed to analyze mutational variations. Findings from this study not only emphasized the potential presence of SARS-CoV-2 in feces, but also its continuing mutational changes and its possible role in fecal-oral transmission.

Rhino-orbito-cerebral mycosis and COVID-19: From bad to worse?

Background:

There has been an increase an alarming rise in invasive mycoses during COVID-19 pandemic, especially during the second wave.

Aims:

Compare the incidence of invasive mycoses in the last three years and study the risk factors, manifestations and outcomes of mycoses in the COVID era.

Methodology:

Multicentric study was conducted across 21 centres in a state of western India over 12-months. The clinico-radiological, laboratory and microbiological features, treatment and outcomes of patients were studied. We also analysed yearly incidence of rhino-orbito-cerebral mycosis.

Results:

There was more than five-times rise in the incidence of invasive mycoses compared to previous two-years. Of the 122 patients analysed, mucor, aspergillus and dual infection were seen in 86.9%, 4.1%, and 7.4% respectively. Fifty-nine percent had simultaneous mycosis and COVID-19 while rest had sequential infection. Common presenting features were headache (91%), facial pain (78.7%), diplopia (66.4%) and vison loss (56.6%). Rhino-orbito-sinusitis was present in 96.7%, meningitis in 6.6%, intracranial mass lesions in 15.6% and strokes in 14.8%. A total of 91.8% patients were diabetic, while 90.2% were treated with steroids during COVID-19 treatment. Mortality was 34.4%.

Conclusion:

Invasive fungal infections having high mortality and morbidity have increased burden on already overburdened healthcare system. Past illnesses, COVID-19 itself and its treatment and environmental factors seem responsible for the rise of fungal infection. Awareness and preventive strategies are the need of hours and larger studies are needed for better understanding of this deadly disease.

Preparedness of Acute Care Facility and a Hospital for COVID-19 Pandemic: What We Did!

Background and aim

India is facing the pandemic of coronavirus disease (COVID-19) just like the whole world. The private sector is the backbone of a healthcare facility in India. Presently, only a few major hospitals in the country are actively dealing with the COVID-19 patients while others are facing troubles due to lack of manpower, management, and required experience to face the pandemic. Despite the lockdown, the cases are ever increasing and each and every hospital in the country should be prepared to face this pandemic the world has never seen before. As one of the largest multispecialty hospitals and a designated COVID center, we have developed and adopted some strategies for better preparedness to face the surge of this pandemic. We would like to share our experience and hope that the strategies laid down and adopted by us will help many other acute care facilities in many parts of India.

Materials and methods

Different strategies are adopted to deal with the crisis situation of the COVID-19 pandemic. Our adopted strategies were directed to mitigate the challenges of administration, hospital space organization, management of staff and supplies, maintenance of standard of care, and specific COVID care and ethics during this pandemic.

Results

Based on strategies adopted by us, we feel more confident and prepared to deal with COVID-19 pandemic.

Conclusion

Our approach for preparing for the COVID-19 pandemic may not be the best one but we believe that the basic managerial principles we adopted will guide many other institutions to find their path in tackling the pandemic in the best possible way.

How to cite this article

Jog S, Kelkar D, Bhat M, Patwardhan S, Godavarthy P, Dhundi U, et al. Preparedness of Acute Care Facility and a Hospital for COVID-19 Pandemic: What We Did! Indian J Crit Care Med 2020;24(6):385-392.

Author Correction: Forearc carbon sink reduces long-term volatile recycling into the mantle

An Amendment to this paper has been published and can be accessed via a link at the top of the paper.

Ureterocolic fistula diagnosed on the basis of diuretic renogram and direct radionuclide cystography

Ureterocolic fistulae are a rare phenomenon and are most commonly seen secondary to obstructive ureteric calculi. These are usually diagnosed on barium enema or intravenous urography. Most of the times, more than one investigation is needed to confirm the findings. We present a case of iatrogenically-induced ureterocolic fistula, diagnosed on renogram and direct radionuclide cystography. This case showcases the possibility of using a renogram study as a diagnostic tool for a suspected ureterocolic fistula. A renogram study also enables to asess the renal function, which is essential in deciding the management.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Adult presentation of congenital muscular torticollis

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results.

Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.

Clinical findings and pro-inflammatory cytokines in dengue patients in Western India: a facility-based study

BACKGROUND

Descriptions of dengue immunopathogenesis have largely relied on data from South-east Asia and America, while India is poorly represented. This study characterizes dengue cases from Pune, Western India, with respect to clinical profile and pro-inflammatory cytokines.

METHODOLOGY/PRINCIPAL FINDINGS

In 2005, 372 clinically suspected dengue cases were tested by MAC-ELISA and RT-PCR for dengue virus (DENV) aetiology. The clinical profile was recorded at the hospital. Circulating levels of IFN-gamma, TNF-alpha, IL-6, and IL-8 were assessed by ELISA and secondary infections were defined by IgM to IgG ratio. Statistical analysis was carried out using the SPSS 11.0 version. Of the 372 individuals, 221 were confirmed to be dengue cases. Three serotypes, DENV-1, 2 and 3 were co-circulating and one case of dual infection was identified. Of 221 cases, 159 presented with Dengue fever (DF) and 62 with Dengue hemorrhagic fever (DHF) of which six had severe DHF and one died of shock. There was a strong association of rash, abdominal pain and conjunctival congestion with DHF. Levels of IFN-gamma were higher in DF whereas IL-6 and IL-8 were higher in DHF cases (p<0.05). The mean levels of the three cytokines were higher in secondary compared to primary infections. Levels of IFN-gamma and IL-8 were higher in early samples collected 2-5 days after onset than late samples collected 6-15 days after onset. IFN-gamma showed significant decreasing time trend (p = 0.005) and IL-8 levels showed increasing trend towards significance in DHF cases (interaction p = 0.059). There was a significant association of IL-8 levels with thrombocytopenia and both IFN-gamma and IL-8 were positively associated with alanine transaminase levels.

CONCLUSIONS/SIGNIFICANCE

Rash, abdominal pain and conjunctival congestion could be prognostic symptoms for DHF. High levels of IL-6 and IL-8 were shown to associate with DHF. The time trend of IFN-gamma and IL-8 levels had greater significance than absolute values in DHF pathogenesis.

Urogynaecology: an ambulatory approach

An ambulatory approach in urogynaecology offers advantages to both patients and providers, offering significant savings on service delivery. This review provides an analysis of and information on procedures available for the ambulatory setup.

EGR3, a novel member of the Egr family of genes encoding immediate-early transcription factors

We have previously described two cellular immediate-early genes, Egr-1 (mouse) and EGR2 (human) that encode zinc finger proteins. Here we report the characterization of a new member of the Egr family referred to as EGR3 (human). This cDNA clone was isolated using low stringency hybridization with the zinc finger domain of Egr-1. The EGR3 cDNA sequence predicts a 387 amino acid (a.a.) protein containing three Cys2-His2 zinc fingers nearly identical to those of Egr-1 and EGR2. This similarity has a functional consequence: EGR3 can activate transcription of a CAT gene linked to the sequence CGCCCCCGC, a cis element which is a target for Egr-1 and EGR2. We show that EGR3 is an immediate-early growth response gene induced by mitogenic stimulation of rodent and human fibroblasts and a monkey kidney epithelial cell line. The EGR3 gene has a single intron and maps to chromosome 8 at bands p21-23.

ACG, the initiator codon for a Sendai virus protein

Deletion and site-directed point mutants of the polycistronic P/C mRNA of Sendai virus revealed that one of the nonstructural proteins of this virus, the C' protein, initiates from an ACG codon. This ACG codon occurs in an optimum sequence context and precedes the first AUG of the P/C mRNA. The results presented in this communication are consistent with the concept that the ribosomes scan the P/C mRNA to initiate several proteins from its different initiator codons. The arrangement of several weak initiator codons in tandem in an mRNA, i.e. non-AUG in optimum sequence context and AUG in suboptimum sequence context, may represent an alternate means to regulate gene expression in eukaryotes and their viruses.

Translation initiation potential of the 5' proximal AUGs of the polycistronic P/C mRNA of Sendai virus. A multipurpose vector for site-specific mutagenesis

To determine the translation initiation potential of the 5' proximal four AUGs of the polycistronic P/C mRNA of Sendai virus, we have developed an efficient system for oligonucleotide-directed site-specific mutagenesis utilizing a plasmid vector which contains the replication origin of the single-stranded DNA phage f1 and the phage SP6 promoter. Utilizing uridine containing single-stranded DNA templates of the plasmid vector carrying the P/C gene we introduced point mutations in all four of the putative initiator codons (AUGs) of the P/C gene. Based on the analysis of in vitro translation products from the SP6 polymerase-directed transcripts of the mutants, the first and second AUG codons were assigned to the P and C proteins, respectively. Proteins detected in vitro, Y1 and Y2, initiated from the third and fourth AUG codons, respectively, and originated within the C reading frame. Since the C' protein is encoded in the same reading frame as the C protein but did not initiate from any of the 5' proximal AUGs, the synthesis of the C' protein may start from a non-AUG initiator codon in the P/C gene.

5-Methyl-2-thiouridine in the tRNA of Candida tropicalis and its localization in lysine tRNA

35S incorporation studies showed that Candida tropicalis tRNA contained two thionucleosides, one of which was identified as 5-methyl-2-thiouridine. The other thionucleoside was alkali labile, and it appeared to be an ester. Pulse-chase experiments suggested that the two thionucleosides were structurally related. 5-Methyl-2-thiouridine was present in one of the lysine tRNAs. This is the first report of the presence of this nucleoside in a yeast tRNA.