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Congenital Zika syndrome, Guillain-Barre Syndrome, dengue, flavivirus, Zika vaccine. [Extracted from the article]

With the introduction of highly active antiretroviral therapy, there has been a dramatic improvement in the clinical course of patients with human immunodeficiency virus infection and acquired immune deficiency syndrome. However, the favorable virological, immunological, and clinical profile of highly active antiretroviral therapy comes at the cost of some common and, at times, severe metabolic adverse effects such as dyslipidemia, body fat dysregulation/lipodystrophy, insulin resistance, and diabetes mellitus. We describe a case of a male patient from North India who developed similar adverse effects including gynecomastia while on the protease inhibitor lopinavir; the mention of such case is rare in the existing literature. [ABSTRACT FROM AUTHOR]

Familial hypercholesterolemia (FH) is a form of primary hyperlipoproteinemia characterized by the presence of high concentrations of serum low density lipoprotein (LDL) cholesterol, increased tendency to form xanthomas and early onset of coronary artery disease. This disease is an autosomal dominant disorder caused by defects in the gene that encode for the LDL receptor. Homozygous familial hypercholesterolemia is a rare occurrence and here we report a case of an 18-year-old girl with familial hypercholesterolemia treated with antilipidemic drugs and controlled only with LDL apheresis. The patient expired after 3 months highlighting the difficulties in management due to economic constraints in a resource limited setting in spite of availability of effective therapy. [ABSTRACT FROM AUTHOR]

Introduction: Patients on central lines are often having multiple morbidities, and invasive devices provide a niche for biofilm formation, which makes central line-associated bloodstream infections (CLABSIs), a serious concern in health-care settings, as the infections difficult to treat. In this study, we evaluated the common bacteria causing CLABSI, and various patient and pathogen factors affecting the clinical outcome. Methods: In the prospective observational study, patients diagnosed with CLABSI were recruited. Extensive clinical, microbiological, and other laboratory workup was done, and observations were recorded. Congo red agar method, tube test, and microtiter plate assay were used for eliciting the biofilm-forming attributes of the bacterial pathogens. Results: Klebsiella pneumoniae was responsible for 48% of CLABSI, followed by Coagulase-negative Staphylococci (16%) and Staphylococcus aureus and Acinetobacter baumannii (12% each). Fifty-six percent of the isolates produced biofilms. The median (interquartile range) duration of hospital stay till death or discharge was 30 (20, 43) days. The all-cause mortality was 44%. Patients having a deranged liver function on the day of diagnosis (P value for total bilirubin 0.001 and for aspartate transaminase 0.02), and those infected with multidrug-resistant organisms (P value = 0.04) had significantly poor prognosis. The difference in the demographic, clinical, laboratory profile, and outcome of patients infected with biofilm producers and nonproducers was not found to be statistically significant. Conclusion: The study throws light on various host and pathogen factors determining the cause and outcome of CLABSI patients. To the best of our knowledge, this is the first study trying to decipher the role of biofilm formation in the virulence of pathogens and the prognosis of CLABSI. [ABSTRACT FROM AUTHOR]

Background & objectives: Acute respiratory distress syndrome (ARDS) is a common disorder in critically ill patients and is associated with high mortality. There is a paucity of literature on this condition from developing countries. This prospective observational study was designed to find out the aetiology, outcomes and predictors of mortality in ARDS. Methods: Sixty four consecutive patients who satisfied American-European Consensus Conference (AECC) definition of ARDS from medical Intensive Care Unit (ICU) of a tertiary care centre in New Delhi, India, were enrolled in the study. Demographic, biochemical and ventilatory variables were recorded for each patient. Baseline measurements of serum interleukin (IL)-1β, IL-6, tumour necrosis factor-alpha (TNF-α), procalcitonin (PCT) and high sensitivity C-reactive protein (hsCRP) were performed. Results: Common causes of ARDS included pneumonia [44/64 (68.7%)], malaria [9/64 (14.1%)] and sepsis [8/64 (12.5%]. Eight of the 64 (12.5%) patients had ARDS due to viral pneumonia. The 28-day mortality was 36/64 (56.2%).Independent predictors of mortality included non-pulmonary organ failure, [Hazard ratio (HR) 7.65; 95% CI 0.98-59.7, P=0.05], Simplified Acute Physiology Score (SAPS-II) [HR 2.36; 95% CI 1.14-4.85, P=0.02] and peak pressure (Ppeak) [HR 1.13; 95% CI 1.00-1.30, P = 0.04] at admission. Interpretation & conclusions: Bacterial and viral pneumonia, malaria and tuberculosis resulted in ARDS in a considerable number of patients. Independent predictors of mortality included non-pulmonary organ failure, SAPS II score and Ppeak at baseline. Elevated levels of biomarkers such as TNF-α, PCT and hsCRP at admission might help in identifying patients at a higher risk of mortality. [ABSTRACT FROM AUTHOR]

Objective: The objective was to study the sensitivity, specificity, and diagnostic accuracy of various computed tomography (CT) chest findings in diagnosing recurrence among pulmonary tuberculosis (PTB) suspects. Materials and Methods: A prospective observational study was conducted in a tertiary care hospital in New Delhi. A total of 130 suspects with a past history of treatment for PTB, who presented with any of the symptoms suggestive of recurrence were included. Sputum-positive, HIV-positive patients, pregnant females, and patients aged <18 years were excluded. Patients underwent CT chest followed by bronchoalveolar lavage (BAL). Results: A total of 62 patients were there in the final analysis. The median age of the patients with recurrent PTB was 27.5 years. Cough was the universal symptom in all these patients (>90%). Hemoptysis was the predominant symptom among patients with chronic pulmonary aspergillosis (66.6%). Necrotic mediastinal lymph nodes had good diagnostic accuracy of 88.71% with area under the curve of 0.806, P < 0.001 in diagnosing recurrent TB. BAL GeneXpert and mycobacteria growth indicator tube had good sensitivity (83.33% and 84.62%, respectively), specificity (100% for both), and excellent diagnostic accuracy (95.16% and 96.36%, respectively) for diagnosing recurrence in sputum negative and sputum scarce patient, (P < 0.001) when compared with composite reference standard. For culture-positive cases, BAL GeneXpert MTB/RIF had 100% sensitivity and 97.73% specificity in diagnosing recurrent PTB patients. Conclusion: The presence of mediastinal necrotic lymph node is the most accurate CT finding that can differentiate recurrent TB from post-TB sequelae. No other single chest CT scan finding had reliable diagnostic accuracy in comparison to microbiological tools in diagnosing recurrence among sputum negative or scarce previously treated PTB suspects. [ABSTRACT FROM AUTHOR]

Background: Hydroxychloroquine (HCQ) had generated considerable interest for coronavirus disease 2019 (COVID-19) prophylaxis. We conducted a prospective observational study at a tertiary care hospital in India, with dedicated COVID-19 care facilities. Objectives: Primary objective was incidence of adverse effects, secondary objective being efficacy in preventing COVID-19. Methods: Healthcare workers were recruited and grouped based on voluntary HCQ prophylaxis as per national guidelines. Side effects in HCQ group were graded in accordance with national cancer institute-common terminology criteria for adverse events (NCI-CTCAE) version 5.0. At 3–7-week follow-up, groups were compared for COVID-19 exposure, symptoms development and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR results. Results: Among 358 participants recruited, 216 (60.3%) were males and mean age was 31.2 ± 6.6 years. Chemoprophylaxis was initiated by 258 (72%) participants. After loading dose, 7 (2.7%) reported grade 2 and 1 (0.4%) grade 3 adverse effects. Discontinuation of HCQ due to side effects was reported in 11 (4.3%) participants. Electrocardiogram was done by 50 (19.4%) participants on HCQ; no abnormalities were noted. A total of 106 (41%) among those taking and 63 (63%) among those not taking HCQ were tested for SARS-CoV-2 due to influenza-like illness or significant exposure. Among all participants, 25 (6.9%, 95% confidence interval [CI] 4.3–9.6) developed COVID-19 during the study period. In the group taking HCQ, 10 (3.9%) tested positive compared to 15 (15%) in the group not taking HCQ (P < 0.001). Odds ratio with HCQ intake was 0.34 (95% CI 0.13–0.83, P = 0.01) and the number needed to treat was 12. Conclusion: HCQ is safe at the recommended dose for pre-exposure prophylaxis of COVID-19. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The study objective was evaluation of amotosalen and ultraviolet A (UVA) illumination-based inactivation of dengue virus (DENV) in blood platelets. MATERIALS AND METHODS: Whole blood was collected from healthy donors and platelet concentrates were prepared at a tertiary care hospital in Gurugram, India. Platelet units collected from five blood group matched individuals were pooled and spiked with DENV. The spiked platelet units were subjected to amotosalen treatment followed by UVA illumination, to evaluate the efficiency of this method for viral inactivation. The treated platelet units were evaluated for the presence of infectious DENV. Amotosalen levels were quantified in the treated samples using high-performance liquid chromatography. RESULTS: The presence of replicating DENV was not observed in spiked platelet units treated with amotosalen and UVA illumination, whereas untreated units contained actively replicating DENV. Amotosalen levels were found to be in the permissible range after photochemical inactivation. CONCLUSIONS: Amotosalen/UVA pathogen inactivation treatment showed efficient inactivation of DENV in platelet components. Therefore, it seems to be a promising method for mitigating the risk of dengue transmission through transfusion of potentially contaminated platelet components in dengue-endemic countries such as India. [ABSTRACT FROM AUTHOR]

Objectives: To study whether a trained convolutional neural network (CNN) can be of assistance to radiologists in differentiating Coronavirus disease (COVID)–positive from COVID-negative patients using chest X-ray (CXR) through an ambispective clinical study. To identify subgroups of patients where artificial intelligence (AI) can be of particular value and analyse what imaging features may have contributed to the performance of AI by means of visualisation techniques. Methods: CXR of 487 patients were classified into [4] categories—normal, classical COVID, indeterminate, and non-COVID by consensus opinion of 2 radiologists. CXR which were classified as "normal" and "indeterminate" were then subjected to analysis by AI, and final categorisation provided as guided by prediction of the network. Precision and recall of the radiologist alone and radiologist assisted by AI were calculated in comparison to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. Attention maps of the CNN were analysed to understand regions in the CXR important to the AI algorithm in making a prediction. Results: The precision of radiologists improved from 65.9 to 81.9% and recall improved from 17.5 to 71.75 when assistance with AI was provided. AI showed 92% accuracy in classifying "normal" CXR into COVID or non-COVID. Analysis of attention maps revealed attention on the cardiac shadow in these "normal" radiographs. Conclusion: This study shows how deployment of an AI algorithm can complement a human expert in the determination of COVID status. Analysis of the detected features suggests possible subtle cardiac changes, laying ground for further investigative studies into possible cardiac changes. Key Points: • Through an ambispective clinical study, we show how assistance with an AI algorithm can improve recall (sensitivity) and precision (positive predictive value) of radiologists in assessing CXR for possible COVID in comparison to RT-PCR. • We show that AI achieves the best results in images classified as "normal" by radiologists. We conjecture that possible subtle cardiac in the CXR, imperceptible to the human eye, may have contributed to this prediction. • The reported results may pave the way for a human computer collaboration whereby the expert with some help from the AI algorithm achieves higher accuracy in predicting COVID status on CXR than previously thought possible when considering either alone. [ABSTRACT FROM AUTHOR]

Dengue is a life-threatening mosquito borne viral disease. We are still in the era of supportive treatment where morbidity and mortality are a major concern. Dengue infection in presence of other co-infections makes this scenario rather worse. Timely recognition and raising alarm to be intensive is the need of the hour for primary care physicians practicing in the community and indoors. This review provides a comprehensive knowledge about the recent trends of coinfection in dengue as well as their management consideration which will be particularly helpful for physicians practicing in rural and remote areas of India. [ABSTRACT FROM AUTHOR]

Introduction: Infections with drug-resistant organisms (DRO) have been associated with poor patient outcomes. To tackle this global problem, it is necessary to understand the risk factors that predispose to infections with DRO. Methodology: This was a prospective observational study conducted over a three-year period at a tertiary-care hospital. Bacterial culture isolates from patients admitted in medicine wards with community or hospital-acquired infections were included. Logistic regression analysis was used to determine risk factors for drug-resistant infections. Results: Of the 295 patients with 323 isolates included, 40 (12.3%) had non-MDR (N-MDR) infections, 86 (26.6 %) had MDR infections and 197 (61%) had possible extensively drug-resistant (P-XDR) infections. History of previous admission in the preceding three months (Odds Ratio, OR = 4.53, 95% Confidence interval, CI = 1.8 - 11.42, p = -0.01), high SOFA score at admission (OR = 1.14, 95% CI = 1.0 - 1.290, p = -0.039) and prolonged duration of ventilation (OR = 1.25, 95% CI = 1.05 - 1.41, p = -0.012) were independently associated P-XDR infections when compared to patients with N-MDR. Conclusions: High rate of multidrug-resistant infections in the studied area is alarming. In this single-centre study, we elicited various risk factors for drug-resistant bacterial infections ranging from patient characteristics to iatrogenic risk factors during the hospital stay. Infections with P-XDR and MDR isolates independently increased hospital and ICU stay duration and were associated with increased mortality. [ABSTRACT FROM AUTHOR]

Myelopathy in central nervous system tuberculosis is notorious for poor outcomes, determined by the severity of inflammation and cord level involved. Acute-onset quadriplegia or paraplegia in these cases represents a neuro-emergency. We report a young female with disseminated tuberculosis who presented with acute onset flaccid quadriparesis with loss of bladder and bowel function. Imaging helped identify the extensive involvement of the neuraxis. We propose that, in addition to anti-tubercular therapy, high-dose corticosteroids such as pulse methylprednisolone may result in a meaningful improvement and show greater rapidity of response in cases of severe central nervous system inflammation such as arachnoiditis or myelopathy. [ABSTRACT FROM AUTHOR]

Arsenic has widespread use in agriculture, in alternative medicine and in treatment of certain malignancies, therefore it is vital to timely recognize and treat arsenic toxicity in a suspected patient. Hemodialysis conventionally is thought to play only a supportive role in managing arsenic toxicity but it can be life-saving when chelation is not possible or available. A middle-aged female with a history of non-dialysis-dependent chronic kidney disease (CKD) was brought to the emergency with altered sensorium. On presentation, she was hemodynamically stable with pallor and exfoliating lesions on palms, hyperkeratotic lesions on soles and hyperpigmented macules on the trunk. Investigations revealed pancytopenia and deranged kidney function tests. In view of skin lesions, the toxicological analysis was sent which revealed high levels of Arsenic (594 and 2,553 mcg/L in blood and urine respectively). Thus, a diagnosis of metabolic encephalopathy with the underlying cause being uremic or/and arsenic intoxication was made. Considering renal failure, she was managed with thrice-weekly hemodialysis. Chelation was not possible due to unavailability of agents during lockdown in Coronavirus disease (COVID-19) pandemic. Following dialysis, there was a significant improvement in sensorium, skin lesions, and pancytopenia depicting the utility of hemodialysis in such cases. Thus, hemodialysis is an effective and perhaps underutilized modality in the treatment of arsenic intoxication with impaired renal function. [ABSTRACT FROM AUTHOR]

Traditionally attributed only to Plasmodium falciparum, Plasmodium vivax has recently been reported to cause a significant burden of complicated malaria cases. The present study aimed to delineate the clinical spectrum and identify predictors for severe disease. This was a prospective observational cohort study conducted at a tertiary care hospital in North India. Patients with acute febrile illness (AFI) aged at least 14 years were included if they were diagnosed with vivax malaria based on rapid kits or peripheral smears. Clinical data and investigations during hospital stay was recorded. 439 cases of acute febrile illness were screened, of whom 50 (11%) were diagnosed with malaria including eight P. falciparum infections. Forty-two vivax malaria cases, 22 (52%) of whom were severe, were followed till discharge or death. The median age of the cohort was 24.5 years (Q1-Q3, 19-36 years), including a total of 29 males (69%). Severe malaria was more frequently associated with historical complaints of oliguria or dyspnea, and examination findings of pallor, splenomegaly or altered sensorium. The following five factors were identified to predict severe disease: prolonged illness over 7 days, symptoms of oliguria or dyspnea, examination findings of pallor or crepitations on auscultation. Malaria accounts for 1 in 10 cases of AFI at our North Indian tertiary care center and approximately half of them present with severe disease. Prolonged duration of disease prior to presentation is a modifiable predictor for severe disease and should be targeted for reducing morbidity. [ABSTRACT FROM AUTHOR]

The clinical profile and risk factors for mortality in dengue fever have evolved over the years. The all-cause mortality in admitted dengue patients is around 6%. We aimed to evaluate the recent change in trends of the clinical characteristics and risk factors for in-hospital mortality in adults with dengue fever. This is a retrospective study on adults with confirmed dengue fever admitted in a medical unit of a tertiary care center in North India. Medical records of confirmed dengue fever patients admitted between January 2011, and December 2016 were reviewed. Chi-squared tests with Bonferroni correction for multiple testing were used to identify risk factors for mortality. 232 records were included, of which 66.8% were males. The mean age was 31.6 ± 14 years. There were 17 deaths with an all-cause mortality rate of 7.3% with 76.5% being classified as severe dengue at admission. Among the 17 mortality cases, dyspnea (47%), tachypnea (86.7%), leucocytosis (58.8%), raised urea (80%), and elevated serum creatinine (52.9%) at presentation were significantly associated with mortality (p < 0.001). Shock at any time during the hospital stay (58.8%) was also found to be significantly associated with mortality (p < 0.001). We found that dyspnea, tachypnea, acute kidney injury, and leucocytosis at presentation was significantly associated with in-hospital mortality. Based on our results, we recommend aggressive management of patients with severe dengue and those with mild/moderate disease with the above risk factors. [ABSTRACT FROM AUTHOR]

Background The global burden of infections due to multidrug-resistant organism (MDRO) has a significant impact on patients' morbidity and mortality along with increased healthcare expenditure. Aim This article estimates the prevalence of MDRO and the spectrum of clinical infectious syndromes caused by these organisms in medical wards of a tertiary care hospital in India. Design and Methods A cross-sectional observational study was performed among patients admitted in medicine wards diagnosed with the various infectious syndromes and one or more clinically significant positive culture at a tertiary care hospital in North India over a period of 18 months. Results Out of 323 clinically significant microbiological culture isolates from 229 patients included in the study, 86 (27%) isolates showed multidrug resistance (MDR) pattern, 197 (61%) isolates showed possible extremely drug-resistance pattern, and only 40 (12%) isolates showed nonmultidrug-resistance pattern of antibiogram. Conclusion The prevalence of MRDOs is high in clinically significant culture isolates from medicine wards in India. This emphasizes the importance of appropriate antibiotic usage and implementation of antibiotic stewardship programs in this part of the world. [ABSTRACT FROM AUTHOR]

The management of patients with brain abscess poses a significant challenge to clinicians in patients with chronic kidney disease. Obtaining a biopsy sample from the affected area is the mainstay in the diagnosis, but it is often unavailable. In most cases, therapy is guided by clinical findings and imaging alone. We discuss three cases of brain abscess- each with a different scenario and discuss the issues faced in management. The first case was a 32-year-old post-renal transplant male patient with a brain abscess due to dematiaceous fungi and was treated with amphotericin. The second case was a 42-year-old female patient with stage 5 chronic kidney disease on maintenance hemodialysis who presented with a brain abscess due to suspected fungal infection based on imaging findings and was managed with antibiotics and voriconazole. The third case was a 42-year-old post-renal transplant male patient who presented with a brain abscess due to nocardiosis and was managed with cotrimoxazole, meropenem and linezolid. We also summarize the approach to the management of brain abscess in resource-limited settings. [ABSTRACT FROM AUTHOR]

Objective: Systemic lupus erythematosus (SLE) is an autoimmune disease with an unknown etiology that can be life threatening. This study aimed to study the cause of mortality among admitted SLE patients over a period of 5 years at a teaching hospital in India. Methods: A 5-year retrospective analysis of mortality in SLE patients admitted under department of medicine of our institute was done. The presenting complaints, treatment history, clinical parameters, laboratory investigations, organ involvement, systemic lupus erythematosus disease activity index (SLEDAI), and cause of mortality were collected from the medical records on a predesigned proforma. A further analysis of two groups based on the cause of mortality was done. Results: In total, 53 death records were analyzed. Mortality in 28 SLE patients was due to high disease activity (Group I) and mortality in 25 patients was attributed due to both high disease activity and concomitant infection (Group II). Most of the patients were female (98%) and mean age of patient was 30.6 years. About 19 patients (35.8%) were diagnosed with SLE during hospital admission. Fever was the most common presenting complaint (69.8%) and lupus nephritis was the most common organ dysfunction seen (84.9%). Myocarditis was observed in 11 patients and 9 patients had cerebrovascular accident. The mean hemoglobin was lower in Group II (7.4 vs. 8.7 g/dL, P = 0.02). The median total leukocyte count was significantly higher in Group II (10,200 vs. 6600, P = 0.02). The mean serum urea and creatinine levels were also significantly higher in Group II (141.41 vs. 87.8 mg/dL, P = 0.006 and 4.7 vs. 1.7, P = 0.0001), respectively. The mean SLEDAI in Group I was 20.8 ± 8.9 and in Group II was17.7 ± 7.5. Bacterial pneumonia (17) was the most common infection, followed by tuberculosis (2) and fungal infection (2). Conclusion: Mortality among SLE patients could be due to disease flare or concomitant infection. Lung is the most common organ affected by infection in these patients. [ABSTRACT FROM AUTHOR]

Mucormycosis is an uncommon aggressive fungal infection usually seen in immunocompromised hosts or patients with burns and trauma. The common presentations include rhino-orbital-cerebral and pulmonary involvement. Osteoarticular involvement is a rare presentation of this disease. We present two cases of osteoarticular mucormycosis of pelvis and long bones of the lower limb, one in a patient with burn injury and other one in a patient with chronic granulomatous disease, hitherto a rarely reported association. Delayed diagnosis in a setting where tuberculosis is a common cause of chronic osteomyelitis, challenges in medical and surgical management of these patients are discussed in this report. [ABSTRACT FROM AUTHOR]

Invasive fungal infections (IFI) are commonly seen in immunosuppressed individuals but their epidemiology in critically ill patients has not been well described. The aim of this study was to determine the frequency, risk factors and outcome of invasive fungal infections in a medical intensive care unit. A prospective observational study was carried out between August 2016 and March 2018 in the medical intensive care unit. Patients above the age of 14 years with endotracheal intubation and/or central venous catheter for at-least three days and sepsis (not responding to 48 hours of intravenous antibiotic therapy) were included in the study. Suitable samples were collected and were subjected to fungal diagnostics. Invasive fungal disease was defined according to standard guidelines. Of the 100 recruited patients, a total of 11 patients had invasive aspergillosis, three patients had invasive candidiasis and one patient had both invasive aspergillosis and mucormycosis. IFI was more commonly seen in patients with auto-immune diseases (p = 0.002, odds ratio-10.13 (95% CI: 2.3-44)). A mortality of 73% was observed in patients with IFI. In conclusion, IFI, especially aspergillosis is grossly underreported in critical settings. Early suspicion, thorough investigation and timely diagnosis may alleviate patients of significant mortality and morbidity. [ABSTRACT FROM AUTHOR]

Acute febrile neutrophilic dermatosis (Sweet’s syndrome) is a rare inflammatory condition which presents as abrupt onset of painful erythematous plaques or nodules, often associated with fever and leucocytosis. Many extracutaneous manifestations are described in literature, but pulmonary manifestations and systemic inflammatory response syndrome (SIRS) are rare. Here we report a case of a 35‑year‑old male who presented with SIRS and pleural effusion. The presence of vesiculobullous and pustular skin lesions raised the suspicion of Sweet’s syndrome and it was confirmed by skin biopsy. Initiation of systemic glucocorticoids lead to complete resolution of symptoms. [ABSTRACT FROM AUTHOR]

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the backbone of effective anti-retroviral therapy in the developing world. Efavirenz is the current NNRTI of choice due to reports of higher incidence of serious adverse events with nevirapine. Majority of patients with Human immunodeficiency virus (HIV) infection in India are still on nevirapine based therapy. The aim of the study was to evaluate the need of shifting these patients to efavirenz based therapy. A cross-sectional study was conducted on adult patients, who were on NNRTI based regimen for more than one year with good adherence. The patients were divided into efavirenz or nevirapine groups based on the treatments they were receiving at the time of study. The different arms were compared based on their clinical and laboratory profile, adverse events and immunological response. A total of 244 patients were recruited. A total of 125 patients were receiving nevirapine based regimen while 119 patients were receiving efavirenz based regimen. There was no significant difference in the frequency of hematological and biochemical derangements between the two groups. There was no difference in the median highest CD4 count achieved during therapy between the two groups. Clinically observed side effects were more common in the efavirenz group. These results suggest that there isn't enough evidence to shift patients tolerating long term nevirapine based therapy to efavirenz based therapy. [ABSTRACT FROM AUTHOR]

The clinical practice guidelines on nosocomial pneumonia recommends an empirical regimen that would work in 95% of the patients based on the local antibiogram. The aim of the study was development of an antibiogram for guiding empiric therapy in settings with high prevalence of multi-drug resistant organisms. A retrospective review of electronic health records (e-hospital portal) was done to analyze all respiratory isolates from patients admitted in medical wards and intensive care unit between May 2016 and May 2017. The samples included brocho-alveolar lavage (BAL), mini broncho-alveolar lavage (mini-BAL) and endotracheal aspirate. The sensitivity pattern (combined and individual) of all bacterial isolates were analysed for commonly used antibiotics and their combinations. Out of the 269 isolates, the most common organisms were Pseudomonas aeruginosa (125, 46%), Acinetobacter baumanni (74, 27%) and Klebsiella pneumoniae (50, 19%). Cefoperazone-sulbactam (43%) had the best sensitivity pattern overall. Cefoperazone-sulbactam plus amikacin (56%) was the combination with the best combined sensitivity overall. There is a high prevalence of resistance in the commonly implicated organisms to the available antibiotics. There is an urgent need for implementation of effective anti-microbial stewardship programmes and development of newer antimicrobials. [ABSTRACT FROM AUTHOR]

Iliopsoas abscess (IPA) is an uncommon diagnosis in medical wards. Herein, we present two unusual cases of IPA. First patient was an elderly diabetic patient who had gas-forming bilateral IPA caused by Escherichia coli. This infection proved fatal and patient succumbed on third day of hospital admission. Second patient was a young boy who had right sided sacroilitis with IPA. Staphylococcus aureus was isolated from the pus culture and patient was successfully treated without any sequelae. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms). Methods: This pre-postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before--after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention. Results: The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits. Conclusions: This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond. [ABSTRACT FROM AUTHOR]

Major difficulty in development of dengue diagnostics is availability of suitable antigens. To overcome this, we made an attempt to develop a peptide based diagnosis which offers significant advantage over other methods. With the help of in silico methods, two epitopes were selected from envelope protein and three from NS1 protein of dengue virus. These were synthesized in combination as three multiple antigenic peptides (MAPs). We have tested 157 dengue positive sera confirmed for NS1 antigen. MAP1 showed 96.81% sera positive for IgM and 68.15% positive for IgG. MAP2 detected 94.90% IgM and 59.23% IgG positive sera. MAP3 also detected 96.17% IgM and 59.87% IgG positive sera. To the best of our knowledge this is the first study describing the use of synthetic multiple antigenic peptides for the diagnosis of dengue infection. This study describes MAPs as a promising tool for the use in serodiagnosis of dengue. [ABSTRACT FROM AUTHOR]

Background. There is lack of reliable predictors of disease severity and mortality in dengue. The present study was carried out to identify these predictors during the 2015 outbreak in India. Methods. This prospective observational study included confirmed adult dengue patients hospitalized between August and November 2015 in a tertiary care centre in New Delhi, India. Appropriate statistical tests were used to compare clinicolaboratory characteristics, derive predictors of severe disease and mortality, and compute a predictive score for mortality. Serotyping was done. Results. Data of 369 patients were analyzed (mean age, 30.9 years; 67% males). Of these, 198 (54%) patients had dengue fever, 125 (34%) had dengue hemorrhagic fever (grade 1 or 2), and 46 (12%) developed dengue shock syndrome (DSS). Twenty-two (6%) patients died. Late presentation to the hospital (≥5 days after onset) and dyspnea at rest were identified as independent predictors of severe disease. Age ≥24 years, dyspnea at rest and altered sensorium were identified as independent predictors of mortality. A clinical risk score was developed (12*age + 14*sensorium + 10*dyspnea), which, if ≥22, predicted mortality with a high sensitivity (81.8%) and specificity (79.2%). The predominant serotypes in Delhi (2015) were dengue virus DENV2 and DENV4. Conclusion. Age ≥24 years, dyspnea at rest, and altered sensorium were identified as independent predictors of mortality. Platelet counts did not determine outcome in dengue patients. Timely referral/access to healthcare is important. The clinical risk score for mortality prediction that was developed in this study can be used in all healthcare settings, after validation in larger cohorts. [ABSTRACT FROM AUTHOR]

Background. There is lack of reliable predictors of disease severity and mortality in dengue. The present study was carried out to identify these predictors during the 2015 outbreak in India. Methods. This prospective observational study included confirmed adult dengue patients hospitalized between August and November 2015 in a tertiary care centre in New Delhi, India. Appropriate statistical tests were used to compare clinicolaboratory characteristics, derive predictors of severe disease and mortality, and compute a predictive score for mortality. Serotyping was done. Results. Data of 369 patients were analyzed (mean age, 30.9 years; 67% males). Of these, 198 (54%) patients had dengue fever, 125 (34%) had dengue hemorrhagic fever (grade 1 or 2), and 46 (12%) developed dengue shock syndrome (DSS). Twenty-two (6%) patients died. Late presentation to the hospital (≥5 days after onset) and dyspnea at rest were identified as independent predictors of severe disease. Age ≥24 years, dyspnea at rest and altered sensorium were identified as independent predictors of mortality. A clinical risk score was developed (12*age + 14*sensorium + 10*dyspnea), which, if ≥22, predicted mortality with a high sensitivity (81.8%) and specificity (79.2%). The predominant serotypes in Delhi (2015) were dengue virus DENV2 and DENV4. Conclusion. Age ≥24 years, dyspnea at rest, and altered sensorium were identified as independent predictors of mortality. Platelet counts did not determine outcome in dengue patients. Timely referral/access to healthcare is important. The clinical risk score for mortality prediction that was developed in this study can be used in all healthcare settings, after validation in larger cohorts. [ABSTRACT FROM AUTHOR]

Background: Procalcitonin is useful for the diagnosis of sepsis but its prognostic value regarding mortality is unclear. This prospective observational study was designed to study the prognostic value of procalcitonin in prediction of 28 day mortality in patients of sepsis. Fifty-four consecutive patients of sepsis, severe sepsis and septic shock defined using the 2001 Consensus Conference SCCM/ESICM/ACCP/ATS/SIS criteria from medical Intensive Care Unit (ICU) of a tertiary care center in New Delhi, India were enrolled from July 2011 to June 2013. Procalcitonin (PCT), C-reactive protein (CRP) measurements were recorded on day 1, day 7 and day 28 of follow up. Results: Procalcitonin value was a better predictor of all-cause short-term mortality than C-reactive protein. Those patients with Procalcitonin levels <7 ng/ml showed higher cumulative survival than those with level [greater than or equal to]7 ng/ml (69.1% vs. 39.5%, p = 0.02). No such effect was observed in relation to C-reactive protein. Procalcitonin levels [greater than or equal to]7 ng/ml predicted mortality with a hazard ratio of 2.6(1.1-6.3). Conclusions: A Procalcitonin value [greater than or equal to]7 ng/ml obtained at the time of admission to the ICU is a predictor of short-term mortality and thus may allow the identification of those septic patients at increased mortality risk, and help improve their treatment. [ABSTRACT FROM AUTHOR]

Abstract: One approach to the development of an HIV vaccine is to design a protein template which can present gp120 epitopes inducing cross-neutralizing antibodies. To select a V3 sequence for immunogen design, we compared the neutralizing activities of 18 anti-V3 monoclonal antibodies (mAbs) derived from Cameroonian and Indian individuals infected with clade AG and C, respectively. It was found that V3 mAbs from the Cameroonian patients were significantly more cross-neutralizing than those from India. Interestingly, superior neutralizing activity of Cameroonian mAbs was also observed among the nine VH5-51/VL lambda genes encoding V3 mAbs which mediate a similar mode of recognition. This correlated with higher relative binding affinity to a variety of gp120s and increased mutation rates in V3 mAbs from Cameroon. These results suggest that clade C V3 is probably weakly immunogenic and that the V3 sequence of CRF02_AG viruses can serve as a plausible template for vaccine immunogen design. [Copyright &y& Elsevier]

Background: Analysis of human monoclonal antibodies (mAbs) developed from HIV-1 infected donors have enormously contributed to the identification of neutralization sensitive epitopes on the HIV-1 envelope glycoprotein. The third variable region (V3) is a crucial target on gp120, primarily due to its involvement in co-receptor (CXCR4 or CCR5) binding and presence of epitopes recognized by broadly neutralizing antibodies. Methods: Thirty-three HIV-1 seropositive drug naive patients (18 males and 15 females) within the age range of 20-57 years (median = 33 years) were recruited in this study for mAb production. The mAbs were selected from EBV transformed cultures with conformationally constrained Cholera-toxin-B containing V3C (V3C-CTB) fusion protein. We tested the mAbs for their binding with HIV-1 derived proteins and peptides by ELISA and for neutralization against HIV-1 viruses by TZM-bl assays. Results: We isolated three anti-V3 mAbs, 277, 903 and 904 from the cells of different individuals. The ELISA binding revealed a subtype-C and subtype-A specific binding of antibody 277 and 903 while mAb 904 exhibited cross reactivity also with subtype-B V3. Epitope mapping of mAbs with overlapping V3 peptides showed exclusive binding to V3 crown. The antibodies displayed high and low neutralizing activity against 2/5 tier 1 and 1/6 tier 2 viruses respectively. Overall, we observed a resistance of the tier 2 viruses to neutralization by the anti-V3 mAbs, despite the exposure of the epitopes recognized by these antibodies on two representative native viruses (Du156.12 and JRFL), suggesting that the affinity of mAb might equally be crucial for neutralization, as the epitope recognition. Conclusions: Our study suggests that the anti-V3 antibodies derived from subtype-C infected Indian patients display neutralization potential against tier 1 viruses while such activity may be limited against more resistant tier 2 viruses. Defining the fine epitope specificities of these mAbs and further experimental manipulations will be helpful in identification of epitopes, unique to clade C or shared with non-clade C viruses, in context of V3 region. [ABSTRACT FROM AUTHOR]

Background & Objective. IRIS is an important complication that occurs during management of HIV-TB coinfection and it poses difficulty in diagnosis. Previous studies have reported variable incidence of IRIS. The present study was undertaken to describe the pattern of TB-associated IRIS using recently proposed consensus case-definitions for TB-IRIS for its use in resource-limited settings. Methods. A prospective analysis of ART-naïve adults started on HAART from November, 2008 toMay, 2010 was done in a tertiary care hospital in north India. A total 224 patients divided into two groups, one with HIV-TB and the other with HIV alone, were followedup for a minimum period of 3 months. The diagnosis of TB was categorised as "definitive" and "probable". Results. Out of a total of 224 patients, 203 completed followup. Paradoxical TB-IRIS occurred in 5 of 123 (4%) HIV-TB patients while 6 of 80 (7.5%) HIV patients developed ART-associated TB. A reduction in plasma viral load was significantly (P = .016) associated with paradoxical TB-IRIS. No identifiable risk factors were associated with the development of ART-associated TB. Conclusion. The consensus case-definitions are useful tools in the diagnosis of TB-associated IRIS. High index of clinical suspicion is required for an early diagnosis. [ABSTRACT FROM AUTHOR]

The viral reverse transcriptase gene was amplified from the plasma of 27 drug-naïve and five drug-experienced HIV patients in Northern India. Follow-up samples of naïve patients after antiretroviral therapy initiation were collected in six patients at 3 months and three patients at 6 months. Phylogenetic analysis revealed two new recombinant forms, CRF_CH and CRF_CK, and an accessory non-nucleoside reverse transcriptase inhibitor mutation E138A, not previously reported from India. The major DRMs found in two 6-month follow-up samples were absent in their baseline blood samples. This is the first follow-up study to determine anti-retroviral drug resistance mutations in Indian HIV patients. [ABSTRACT FROM AUTHOR]

Problem Antiretroviral therapy (ART) programmes have been successful in several countries. However, whether they would succeed as part of a national programme in a resource-constrained setting such as India is not clear. The outcomes and specific problems encountered in such a setting have not been adequately studied. Approach We assessed the efficacy and functioning of India's national ART programme in a tertiary care centre in northern India. All ART-naive patients started on ART between May 2005 and October 2006 were included in the study and were followed until 31 April 2008. Periodic clinical and laboratory evaluations were carried out in accordance with national guidelines. Changes in CD4+ lymphocyte count, body weight and body mass index were assessed at follow-up, and the operational problems analysed. Local setting The setting was a tertiary care centre in northern India with a mixed population of patients, mostly of low socioeconomic status. The centre is reasonably well resourced but faces constraints in health-care delivery, such as lack of adequate human resources and a high patient load. Relevant changes The response to ART in the cohort studied was comparable to that reported from other countries. However, the programme had a high attrition rate, possibly due to patient-related factors and operational constraints. Lessons learnt A high rate of attrition can affect the overall efficacy and functioning of an ART programme. Addressing the issues causing attrition might improve patient outcomes in India and in other resource-constrained countries. [ABSTRACT FROM AUTHOR]

Background Cardiac involvement in dengue fever is underdiagnosed due to low index of suspicion and overlapping clinical manifestations of capillary leak associated with dengue. The frequency of subclinical dengue myocarditis and its relative contribution to the hemodynamic instability in severe dengue needs to be explored. We studied the prevalence of myocarditis and clinical outcomes among admitted patients with dengue. Methods A prospective observational study was carried out in admitted patients with age between 18 and 65 years having confirmed dengue (NS1/IgM ELISA). Patients with electrolyte abnormalities or on medications affecting heat rhythm/ rate, pre-existing heart disease were excluded. The baseline demographic, clinical and laboratory parameters were collected. A baseline ECG was done and repeated every second day. Trop-I and NT-proBNP were done at baseline and repeated only if elevated at baseline or there were ECG changes. The cardiac enzymes were measured using enzyme-linked fluorescent assay (VIDAS, bioMérieux, France). Patients with elevated enzymes underwent 2-dimensional echocardiography. Diagnosis of myocarditis was as per ESC 2013 criteria. Fluid management was as per WHO guidelines (2009). Results A total of 183 patients were recruited with median age of 29 years (IQR 21, 37) and 31% were females. Dengue with warning signs was present in 80 (44%) and severe dengue in 45 (25%) patients. Cardiac enzymes were elevated in 27 (15%) patients (cTnI in 25, NT-proBNP in 22). Among these 27 patients, 11 [6% (2.6–9.4, 95% CI)] had echo evidence and diagnosed as having myocarditis according to ESC 2013 criteria (Figure 1). Clinical features of fluid overload were more common in myocarditis group [8 (73%) vs 4 (2%), P = Overall, 5 (2.7%) patients expired, all of them had myocarditis (5/11 = 45%). These patients had severe dengue, 2 patients developed hospital-acquired pneumonia and 1 had malaria co-infection. Among patients with raised enzymes and normal echo (n = 16), 3 patients developed clinical signs of fluid overload compared with only 1 out of 156 patients without raised enzymes (P < 0.01). Conclusion Myocarditis in admitted patients with dengue is not uncommon [6% (2.6–9.4, 95% CI)] and may lead to a complicated disease course. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Diagnostic importance of asymptomatic cryptococcal antigenemia is being increasingly recognized in the last few years. Recently, WHO (World Health Organization) has recommended routine screening of CrAg (cryptococcal antigen) among PLHA with CD4 ≤100/mm3, albeit this procedure is not yet adopted by many developing countries including India. Methods We conducted a prospective observational study in a large tertiary care center of North India, upon ethical clearance. Latex agglutination test was performed to assess serum CrAg levels, followed by the lumbar puncture for detection of CrAg levels in the CSF. We analyzed the prevalence and treatment outcomes of cryptococcal antigenemia among PLHA with CD4 ≤ 100 cells/mm3. Detailed clinical examination was conducted, with follow-up of upto 3 months. Multivariate analysis was performed for the estimation of risk factors. Results The mean age (years) and BMI (kg/m2) of all the participants were 41.4 ± 11.2 and 22.1 ± 2.6, respectively. Notably, the mean CD4 count (cu.mm) at the time of recruitment was 62.3 ± 20.5. Noteworthy, 62 (60.8%) of the patients were ART naïve. We found 9.8% (n = 10) of the patients were positive for serum CrAg, and only 2.9% (n = 3) had clinical features of meningitis and 6.8% (n = 7) were asymptomatic (subclinical) CrAg positive. Strikingly, 3.9% (n = 4) of the asymptomatic cryptococcal antigenemia patients were also positive for CrAg in CSF, with 1.9% (n = 2) were only serum CrAg positive, and 1 patient was lost to follow-up (Graph 1). Multivariate analysis revealed that patients with long duration of HIV (P = 0.04), headache symptoms (P = 0.004) and possessing features of meningismus (P value=0.08) are more likely to be CrAg positive. Conversely, patients on fluconazole were protective against cryptococcal antigenemia (P = 0.1) as shown in Table 1. Overall mortality observed was 11.3% among advanced HIV patients. Moreover, mortality in CrAg-positive patients was 33.3% in comparison to CrAg-negative patients who had 9% (P = 0.06) in 3-months follow-up. Conclusion Cryptococcal antigenemia is common (9.8%) among patients with CD4 count ≤100/mm3 in India. Screening for CrAg should be made routine for PLHA with CD4 count ≤100/mm3 and if required preemptive treatment to be given in this regard. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]