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Rabies is a fatal aggressive disease of the nervous system which predominantly causes motor and autonomic dysfunction. Limbic system involvement has been reported rarely, with limited data on its prevalence. The diagnosis becomes challenging when a patient presents with limbic system involvement in the absence of a clear history of an animal bite. We herein illustrate a case of a young man who presented with recurrent episodes of inappropriate ejaculation. He eventually developed hydrophobia and aerophobia, leading to a diagnosis of rabies. This case emphasises the importance of considering the possibility of rabies encephalitis when a patient presents with symptoms of limbic system involvement since early diagnosis helps in instituting appropriate public health measures and reducing exposure to infection. Furthermore, high-quality intensive care with supportive management is the mainstay of therapy in such patients until we have novel and effective antiviral drugs for rabies treatment.

We present a case of a 51-year-old immunosuppressed man with underlying chronic lymphoproliferative leukaemia (CLL), who presented to us in emergency with breathlessness, hydrophobia, anxiety and restlessness. He had a history of category 3 dog bite 2 months ago and had received a full course of rabies immunoglobulin and antirabies vaccine (ARV) as per the national schedule. As there were frank clinical reports of rabies, the patient was managed according to Milwaukee regimen. The patients died within a week of the appearance of symptoms. The brain autopsy revealed Negri bodies conforming the mortality due to rabies.Immunosuppressed patients, like our patient who had CLL have low antibody formation after rabies prophylaxis. Antibody titres in immunosuppressed patients need to be measured after the 2–4 weeks of the last injection of ARV to decide whether a booster of ARV needs to be administered or not.

Herpes simplex encephalitis is the most common cause of sporadic viral encephalitis worldwide but presents as a diagnostic challenge at many settings due to its non-specific symptoms, which can be easily mistaken for systemic infection or metabolic encephalopathy. It has diverse range of presentations from fever, altered sensorium, nausea, vomiting, meningismus to seizures, neurological deficits and coma in advanced stages. It is associated with significant morbidity and mortality if treatment is delayed or inadequate. We here discuss a case of Herpes simplex virus (HSV) encephalitis which rapidly progressed to result in irreversible neurological insult due to delayed diagnosis and treatment.

Background It is reported that patients who have recovered from Covid-19 continue to experience various symptoms and adverse outcomes. However, this aspect has not been studied well. We aimed to evaluate these variables and the perceived impact of Covid-19 among patients discharged from a Covid hospital in northern India. Methods We conducted this study among patients discharged from a Covid-19 hospital in northern India in June 2020. As per the official policy at that time, patients detected to have Covid-19 (symptomatically or via contact tracing) were mandatorily admitted. A sequential, mixed-methods design was followed. Patients discharged from the hospital were contacted telephonically, and the cross-sectional prevalence of symptoms, the prevalence of depression and anxiety and the social consequences of admission were assessed. A subgroup of patients was interviewed for qualitative assessment of their experience. Results A total of 274 patients provided consent and were assessed, of which 8 patients underwent detailed interviews. The prevalence of somatic symptoms was 3.4%; 36.2% of the patients had depressive and 12% of the patients had anxiety symptoms. A majority of patients experienced adverse social and economic consequences of hospitalization for Covid-19. These themes were reinforced by a qualitative analysis of in-depth interviews. Conclusions Our study population experienced a high prevalence of adverse psychosocial consequences of Covid-19. These included depression and anxiety symptoms, stigma and economic and occupational consequences. These deserve more recognition and study.

Background: The inflammatory state that characterizes COVID-19 may contribute to depression, anxiety, other morbidities, and mortality. Interleukin-6 blocker tocilizumab has been used as a treatment modality in COVID-19 as an anti-inflammatory agent. Tocilizumab has also been studied for its potential use in preventing depression in other patient groups, with mixed results. This study was designed to study subsequent depression, anxiety, and quality of life (QOL) in patients treated with tocilizumab plus standard care versus standard care alone, for moderate to severe COVID-19 pneumonia. Methods: Patients admitted with moderate to severe COVID pneumonia, treated with tocilizumab plus standard treatment, and discharged from the hospital were identified. Age- and gender-matched controls who had received standard treatment alone for COVID-19 pneumonia during the same time frame were identified. After obtaining consent, these patients were followed up and assessed at 3 and 6 months on measures of depression (PHQ-9), anxiety (GAD-7), and QOL (EQ-5D-5L). Results: 39 patients in the tocilizumab group and 41 in the control group were followed up at 3 and 6 months. Patients in both groups were comparable in sociodemographic and clinical parameters. The prevalence of clinically significant depression in the tocilizumab group at 3 and 6 months was 33.33% and 5.12%, respectively, whereas in control group it was 31.7% and 4.87%, respectively. Analysis of EQ-5D health profiles revealed that the maximum problems were reported in the dimension of mobility: 43.7% at 3 months and 35% at 6 months. Conclusions: Depressive and anxiety symptoms and impairment in QOL were reported more frequently and with greater severity in patients in the tocilizumab group at three months but not at six months. Psychological morbidity and impairment in QOL were modest and improved from 3 to 6 months.

This study aimed to investigate community knowledge, attitudes, practice, and concerns of adults 18-45yrs towards COVID 19 vaccinations in Chandigarh, India. A rapid online survey was done, and forms from 731 people were collected from 24.08.21 to 5.10.21. The primary outcome variable was the general public's willingness, knowledge, and attitude towards COVID-19 vaccination. The associated factors were identified using regression analysis. A sample of 73% of people participated and completed the study questionnaires. Only 70.3% of the people received the vaccination, and 70.9% of participants gave no history of previous COVID-19 infection. Just above half of the participants, 50.2%, believed to know the vaccine's effectiveness, whereas 88.1 % (644) participants understood the importance of vaccination against this disease. Despite limitations, surveys are a suitable method to evaluate and assess attitudes and concerns of the general population about COVID-19 vaccination.

Introduction: Scrub typhus in pregnancy may present with varying clinical spectrum ranging from mild febrile illness to multi-organ dysfunction. Severe form of untreated disease may result in maternal and/or fetal death. We present the case report of a primigravida in her third trimester of pregnancy with scrub typhus that faced “maternal near miss” and fetal demise. Case: A 25-year-old primigravidaat 36 weeks of gestation was referred to us with fever, headache, and malaise for 15 days and progressive dyspnea for two days. She was being treated with antipyretics and non-specific antibiotics before referral. She had tachycardia, hypotension, tachypnoea, orthopnea, oxygen saturation of 90% on room air, and generalized anasarca. Investigations revealed thrombocytopenia, deranged renal function tests, and increased procalcitonin. Azithromycin and ceftriaxone were started empirically. ELISA for Scrub typhus was positive. Subsequently, an eschar was found below left breast. Her condition improved with resuscitation, supportive therapy, and definitive treatment. Patient had spontaneous labor within 24 hours of admission resulting in vaginal delivery. She had intrapartum stillbirth. After delivery, she again developed respiratory distress requiring intubation. The chest Xray showed a deteriorating picture with consolidation in right upper lung and bilateral reticulo-nodular opacities. Antibiotics were switched to meropenem and doxycycline 100mg twice a day. Fever subsided after day-4 postpartum and she was gradually weaned off from the ventilator. Conclusions: It is important to consider this differential early in the course of illness especially in tropical countries. Delay in diagnosis and hence, treatment can result in catastrophic outcome.

BackgroundGastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity.AimTo conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT).MethodsWe searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale.ResultsThirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07–0.20, I2 = 89%) and 0.27 (95% CI 0.21–0.33, I2 = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65–0.86, I2 = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40–0.85, I2 = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13–0.32, I2 = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09–0.21, I2 = 0%).ConclusionStricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

The efficacy of Hydroxychloroquine (HCQ) as post-exposure prophylaxis (PEP) for the prevention of COVID-19 was contentious. In this randomized control double-blind clinical trial, asymptomatic individuals with direct contact with laboratory-confirmed COVID-19 cases were randomized into PEP/HCQ (N = 574) and control/placebo (N = 594) group. The PEP/HCQ group received tablet HCQ 400 mg q 12 hourly on day one followed by 400 mg once weekly for 3 weeks, and the control/Placebo group received matching Placebo. The incidence of COVID-19 was similar (p = 0.761) in PEP [N = 24 out of 574, (4.2%)] and control [N = 27 out of 594, (4.5%)] groups. Total absolute risk reduction for the incidence of new-onset COVID-19 was -0.3% points with an overall relative risk of 0.91 (95% confidence interval, 0.52 to 1.60) and the number needed to treat (NNT) was 333 to prevent the incident of one case of COVID-19. The study found that, PEP with HCQ was not advantageous for the prevention of COVID-19 in asymptomatic individuals with high risk for SARS-CoV-2 infection. Though HCQ is a safer drug, the practice of irrational and indiscriminate use of HCQ for COVID-19 should be restrained with better pharmacovigilance.

Background: The persistence of the COVID-19 pandemic besides its current resurgence and continuously increasing fatalities indicates a vital need for severity assessment at its early stages. Recent studies have already ascribed mortality to chronic inflammation. But the part of trace elements, especially zinc and copper that have been known to possess antiviral roles for a long time is least studied in COVID-19. Methods: The study comprised 122 COVID-19-positive participants admitted to the tertiary care hospital. Among them, eighty-one (~66%) were admitted to ICU under high severity. Levels of Zn and Cu along with CRP were analyzed and compared among ICU and non-ICU admitted patients. Using ROC analysis, the potential and precise levels for defining severity were determined. Results: We found a significant reduction in Zn levels (p=0.001) in ICU-admitted patients compared to the non-ICU group which was more pronounced in females and patients aged above 50 years. Reduction in the levels of Zn is accompanied by elevated CRP levels (pConclusions: The present study was primarily aimed to predict the status of zinc and copper in COVID-19 patients and their utility as a prognostic tool for deciding the severity. Our findings indicate that CRP to Zn ratio might feasibly be used to predict the progression of COVID-19 toward severity. Keywords: COVID-19, Severity, Zinc, Copper, CRP

Haemophagocytic lymphohistiocytosis occurs due to an uncontrolled inflammatory state and can be life threatening. Common triggers are infections, autoimmune diseases, malignancy or can be familial. Early treatment is life-saving especially in cases due to secondary infections. Here we present a rare case of haemophagocytic lymphohistiocytosis in visceral Leishmaniasis, where complete response resulted following treatment of the primary disease.

Vaccination against coronavirus disease 2019 (COVID-19) is one of the most effective tools to curb the pandemic. Multiple vaccine candidates based on different platforms are available for emergency use presently. However, in common all the vaccines target spike protein, which is a dominant immunogen of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). Adequate immunogenicity and efficacy are demonstrated by many of the vaccines in clinical phase III trials. The emergence of the new variant of concern is believed to be associated with less susceptibility to the post-infection or post-vaccination mounted immunity. It is a global concern currently threatening the progression of the vaccination drive. Nevertheless, the results of the presently available phase III clinical trials promote COVID-19 vaccination to prevent disease severity and COVID-19 related deaths. Cross-immunity towards the new variants of concern especially against the South African variant is yet to be explored and managed adequately.

Background The spectrum of infections causing the above acute onset fever with jaundice has changed over the last few years from the conventional hepatotropic viruses to new emerging infections. Methods 250 adult patients ≥ 14 years of age) with acute fever (body temperature > 101ᵒF of 14 days or less in duration) without any localized source of infection on initial clinical evaluation accompanied with jaundice (hyperbilirubinemia ≥ 1.5 mg/dl or elevation of ALT or AST ≥ three times upper limit) were enrolled.All these patients with fever and jaundice were evaluated on the basis of a standard proforma and were evaluated for malaria (peripheral smears/rapid diagnostic kits), scrub typhus( PCR /IgM ELISA), leptospirosis(IgM ELISA), enteric fever by blood cultures and dengue by dengue (NS1 antigen test and IgM ELISA), Hepatitis(IgM ELISA of EBV/HSV, IgM ELISA of HAV/HEV and HBsAg with IgM HBc ELISA if HBsAg positive) Results 62.5 % were males and 37.5 % were females. The mean duration of fever before the presentation was 8.1 ± 2.58 days. 10 patients (4%) died, while 133 patients (96%) improved with treatment. Scrub typhus 57 (22.8%), Hepatitis E 33 (13.2%), malaria 9 (3.6%), dengue fever, enteric fever, hepatitis A and leptospirosis in 26 (10.4%), 6 (2.4%), 6 (2.4%) patients and 4 (1.6%) patient respectively were the prominent aetiology a patient presenting with fever and jaundice. Probable sepsis (Fulfilling SIRS criteria with a negative culture) accounted for 40(16%) patients. In 69(27.6%) cases no diagnosis could be made on serological testing Conjunctival suffusion (OR=23.17), respiratory crepitations (OR=5.17), thrombocytopenia (OR=1.14), normal INR (OR=0.29) were significant predictors of a diagnosis of scrub typhus in patients with fever and jaundice. Severe anaemia (Hb< 8), Hypoalbuminemia, severe thrombocytopenia (Platelet count < 50,000) and a near-normal INR at admission were predictors of a malarial vs a viral aetiology of Tropical jaundice. Co-infection with scrub typhus and malaria was seen in 6 patients (vivax-5 and falciparum-1) and viral hepatitis A & E was observed in 10 patients. Conclusion Neglected Tropical diseases like Scrub typhus infection is emerging as common aetiology of acute onset tropical jaundice in adults presenting to emergency services. Disclosures All Authors: No reported disclosures.

Background Varicella, Hepatitis-A and Dengue cause significant disease burden in our country. Estimation of age-wise seroprevalence of antibodies against these diseases not only help us in understanding age-specific incidence rates and susceptibility, but also help policy makers in deciding need and timing of vaccination. None of these vaccines are part of current national immunization program in India, yet. Methods In this observational cross-sectional study, apparently healthy children (9-12 years), adolescents (15-18 years) and adults (25-30 years) attending OPD of a tertiary care hospital in Northern India over two-year period (July 17- June 19) were enrolled after taking informed written consent, and their 3-ml venous blood sample was collected. Ethical clearance was obtained from Institute Ethics committee, before enrolling subjects. Serum was tested for IgG antibodies using specific commercial ELISA kits. Those who received received Hepatitis-A or Varicella vaccination in past were excluded from enrollment. Results Out of total 240 subjects (M:F=117:123) enrolled, 75 were children, 75 adolescents and 90 adults in specified age groups. Mean age in these three groups were 11.04, 16.52 and 26.53 years respectively. In our study, antibodies (IgG) against Varicella were >12 U/ml (seroprotective) in 36% (27/75), 74.6% (56/75), 64.5% (58/90) in children, adolescent and adults in specified age groups, respectively. Similarly, the antibodies (IgG) against Hepatitis-A were >10 U/ml (seroprotective) in above three groups were 68% (51/75), 85.3% (64/75), 95.5% (86/90). For dengue IgG antibodies also, seropositivity rates in above three groups were 37.3% (28/75), 62.7% (47/75), 53.3% (48/90). Conclusion Large proportion of children, adolescents and adults remain susceptible to Varicella and Hepatitis-A infection in India. Early childhood vaccination with Varicella and Hepatitis-A vaccines should be a part of National Immunization Programme in India, as a part of preventive strategy. Our study also showed a large proportion of children, adolescents and adults remain seronegative for Dengue antibodies in various age groups. Therefore, if currently available dengue vaccine (Dengvaxia) has to be used in our population, it can only be used after individual screening. Disclosures All Authors: No reported disclosures.

Measles continues to result in focal outbreaks in India, despite over three decades of universal infant vaccination. The aims of this study were to examine measles immunity in the population of Chandigarh, India, and to compare immunity by vaccination vs. natural infection. In a cross-sectional study of individuals 1-60 years selected from 30 communities within Chandigarh during 2017-2018, measles immunity was assessed using serological surveys. Seropositivity was compared across demographic groups, and by prior history of vaccination and natural history of infection. Among those 1-20 years old, measles seropositivity, and histories of measles vaccination or prior measles diagnosis were separately assessed as outcomes in logistic regression models, with demographic factors as independent variables. Among 1690 participants, 94% were seropositive, and 6% had borderline or negative antibody levels. Of those positive, 30% had prior vaccination, 16% had a history of natural infection, and 54% had an unknown history. Over 50% of individuals among those20 years old, had unknown history of immunity. In the multivariable regression models, vaccination was more common in younger ages (P .0001), and in males compared to females (P = .0220), and in those with more education (P .0001). The majority of the population was seropositive, and seropositivity increased with age. Older age groups were more likely to be protected because of previous natural infection, whereas younger age groups were protected by vaccination. There was inequity in vaccination coverage by gender, and maternal education status.

Monkeypox is a zoonotic virus belonging to the Orthopoxvirus genus. Previously endemic to Africa, outbreaks have been reported from all over the world, the largest of which is currently ongoing. Dermatologists are principally involved in recognition and diagnosis of the infection. This narrative review primarily focuses on clinical manifestations and highlights the unique epidemiological features of current outbreak. Lesions observed during the current outbreak lack the evolution described in endemic disease. Polymorphic lesions are common and may be confined to anogenital area. Onset of "prodromal" symptoms may coincide with onset of skin rash, and these may be altogether absent. Mortality rates observed are low. The exanthem should be differentiated from other infections such as herpes, molluscum contagiosum, smallpox, and other poxvirus infections. Presentation as an isolated genital lesion warrants differentiation from syphilis, chancroid, and other sexually transmitted diseases. Close intimate contact during sexual encounters is the primary mode of transmission, and other coexisting sexually transmitted infections are frequently diagnosed.

Purpose Etiological spectrum of fever in pregnant women and its impact on fetomaternal outcomes were studied. Methods This was a hospital-based prospective study, conducted over 12 months. All pregnant women with fever were screened and detailed etiological evaluation carried out. Maternal and foetal outcomes were noted. Results One hundred and eighty-one pregnant women with fever were included. Common causes were dengue 44 (24.3%), hepatitis E 26 (14.4%) and urinary tract infection (UTI) 22 (12.2%). Mosquito-borne diseases accounted for the highest burden 61 (33.7%). Second most common were diseases transmitted by feco-oral route 46 (25.4%). Maternal deaths occurred in 29 (16%) patients. Common causes of death were hepatitis E infection in 9 of 26 (34.6%) cases, dengue in 7 of 44 (15.9%) and tuberculosis in 5 of 11 (45.5%) cases. Conclusion Dengue, hepatitis E and UTI were the most common causes of fever during pregnancy. Most cases were caused by vector- and water-borne diseases and thus potentially preventable. Overall maternal mortality was 16%.

Cardiovascular diseases (CVDs) contribute to most of the potentially preventable burden through early risk assessment. Nurse-led CVD risk assessment is an effective strategy to address the human resource crisis for CVD prevention. An interventional study was conducted in medicine wards of a tertiary care hospital in North India to train nurses in CVD risk assessment and its communication. All bedside nurses (n = 30) of selected wards were enrolled and trained in CVD risk assessment and communication using WHO/ISH risk prediction charts. Once fully trained, each nurse enrolled patients (40 years of age) from their respective wards to assess and communicate CVD risk. To calculate the reliability of risk assessment, investigator simultaneously assessed CVD risk with nurses. The mean age of nurses was 32.07 ± 6.31 years. The results revealed that training significantly increased the knowledge of nursing personnel (P0.001). There was perfect inter-rater reliability agreement (Cohen's k = 0.929) between nurses and investigators while assessing CVD risk. Nurses demonstrated good communication skills. The study concluded that nurses can be trained successfully in CVD risk assessment and communication. The study recommends the task shifting of CVD risk assessment to nurses after providing proper training.

The second pandemic of the 21st century, the Coronavirus Disease – 2019, has kept the entire world on its toes. The virus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), seems to have an entire deck of tricks up its sleeve. The brash and acerbic disease course has left the entire world gasping. A sour understanding of the virus evolves, our knowledge base at this point is rather nascent. While the rate of infection is highest among the younger age groups, the Case Fatality Rate seems to be five to seven-fold higher in patients aged 65 years and above. With unforeseen restraints and stern preventive policies in place worldwide, the core principles of Geriatrics seem to have taken a backseat. Social distancing might’ve turned into social suppression, and the phenomena of immunosenescence and frailty leave our elderly population with an oligosymptomatic illness, which is, on many occasions, neglected on a personal, familial or even healthcare level, thus, erring on the gravity of the illness. Patients and medical personnel in hospice facilities and long-term care facilities (LTCFs) face unique and unprecedented challenges. With atypical presentations, multimorbidities, and multiple psychosocial facets, the Coronavirus Disease-2019 presents a rather interesting challenge in the care and management of older adults.

Despite an essential differential diagnosis for fever of unknown origin (FUO) in young adults, adult-onset Still's disease (AOSD) is infrequently considered and remained underdiagnosed in low-middle-income countries. The present study analyzed the clinical, serological, radiological, and pathological characteristics of AOSD presented as FUO in India. A hospital-based retrospective study of patients aged 13 years admitted with FUO and later diagnosed with AOSD in Postgraduate Institute of Medical Education and Research, Chandigarh (India), was conducted between January 2014 and December 2020. Petersdorf and Beeson's criteria were used to define FUO. The diagnosis of AOSD was made based on Yamaguchi's criteria. Twenty-seven patients (median age 26 years, 14 females) were enrolled. All presented with intermittent fever with a median duration of 10 weeks. The typical features of AOSD at admission were arthralgia (n = 24), hepatosplenomegaly (n = 21), spiking fever ≥ 39 °C (n = 19), lymphadenopathy (n = 18), typical rash (n = 17), and sore throat (n = 11). Leukocytosis (n = 25) and neutrophilia (n = 19) were frequent. Hyperferritinemia was universal (range, 700-145,003 ng/ml; ≥ 2000, n = 23). At admission, AOSD was suspected in only nine FUO cases, while tuberculosis (n = 16), undifferentiated connective tissue disorder (n = 14), and lymphoproliferative disorder (n = 11) were common diagnostic possibilities. Crispin et al. clinical scale detected AOSD in only 15 (55.5%) FUO patients. Whole-body imaging (n = 27), including fluorodeoxyglucose positron emission tomography (n = 12), demonstrated reticuloendothelial organ-system involvement and serositis. Seventeen (63%) patients had macrophage activation syndrome at the time of AOSD diagnosis. AOSD FUO presents with typical but nonspecific features; thus, early differentiation from common causes (e.g., tuberculosis, lymphoma) is difficult. Macrophage activation syndrome is common in AOSD with FUO presentation.

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a global health problem, India being the second most affected country. The kinetics of antibody response to SARS-CoV-2 in Indian population is not studied yet. To understand serological response in relation to age, gender, time period and severity of disease, Roche Elecsys anti-SARS-CoV-2 test was used which analysed both IgM and IgG. One hundred and three COVID-19 patients were enrolled. Seropositivity was seen in 64% of patients, with 33% at ≤ 7 days, 62% between 8 and 15 days and 81% at ≥ 16 days from the time of admission. Men (65%) showed higher antibody response than women (59%), whereas no difference was observed in seropositivity with respect to age of the patients. Dynamics of antibody responses revealed individual variations. Patients in ICU had higher antibody reactivity with 67% positivity as compared to 60% positivity in non-ICU patients. Kinetics of antibody response during COVID-19 disease varied in relation to gender, age, time period and severity and these factors might play an important role in treatment and control of COVID-19.

In the modern era, the relative ease and faster speed of travel have made the world a global village. An increasing number of people are traveling to distant and sometimes exotic locations for vacation/leisure or at times for business purposes. Along with the experiences of far-fetched lands, sometimes they bring bugs/organisms that are not native to their motherland. This makes the diagnosis and management of illnesses in a traveler challenging. In this review, we have tried to outline a management protocol for travelers returning with fever, with specific emphasis on trypanosomiasis and schistosomiasis. How to cite this article: Suri V, Bhalla A. Tropical Infections in Returning Travelers. Indian J Crit Care Med 2021;25(Suppl 2):S175–S183.

Background Schizophrenia is a life-shortening disease. The standardized mortality ratio has been higher than that of the general population, and it has doubled what it was 3-4 decades ago. This rise is mostly attributed to the increased cardiovascular risk associated with high second-generation antipsychotic (SGA) use. Evidence from the first-generation antipsychotic (FGA) era shows a lower prevalence of hypertension (HTN) but data regarding SGAs is scarce. Purpose The purpose of the study was to assess the prevalence of HTN and related factors using standardized methodology in patients with schizophrenia on treatment with SGAs. Methods A cross-sectional study through convenient sampling was done. Blood pressure, anthropometry, physical activity, and health-related lifestyle factors were assessed using the standard World Health Organization (WHO) methodology of cardiovascular survey methods and the Global Physical Activity Questionnaire (GPAQ) version 2. The prevalence of HTN, obesity, inadequate physical activity, and other demographic and clinical correlates like antipsychotic use, duration of illness, and family history of non-communicable diseases (NCDs) were studied. Results The prevalence of HTN is 20.50%, and it increases with age. SGAs with the use of a single agent are the most common. In total, 45.50% of persons with schizophrenia have a positive family history of a NCD; 22.00% and 07.50% are current tobacco and alcohol users, respectively; and 70% have abdominal obesity, and 54% have generalized obesity. Waist circumference, obesity, and family history of NCDs are significant correlates of HTN. A family history of NCDs is the most significant predictor. Conclusion The prevalence of HTN is lower than that of the general population despite the high prevalence of SGA use, obesity, and inadequate physical activity.

Objectives To describe the epidemiological and clinical characteristics and outcome of hospitalized children with COVID-19 during the initial phase of the pandemic. Methods This was a cross-sectional descriptive study conducted at the dedicated COVID-19 hospital of a tertiary care referral center in North India. Consecutive children aged 14 y or younger who tested positive for SARS-CoV-2 by RT-PCR from nasopharyngeal swab between 1 April 2020 and 15 July 2020 were included. Results Of 31 children with median (IQR) age of 33 (9-96) mo, 9 (29%) were infants. About 74% (n = 23) had history of household contact. Comorbidities were noted in 6 (19%) children. More than half (58%) were asymptomatic. Of 13 symptomatic children, median (IQR) duration of symptoms was 2 (1-5.5) d. Fever (32%) was most common followed by cough (19%), rapid breathing (13%), diarrhea (10%) and vomiting (10%). Severe [n = 4, 13%] and critical [n = 1, 3%] illnesses were noted more commonly in infants with comorbidities. Three (10%) children required PICU admission and invasive ventilation; one died. Median (IQR) length of hospital stay was 15 (11-20) d. Follow up RT-PCR before discharge was performed in 17 children and the median (IQR) duration to RT-PCR negativity was 16 (12-19) d. Conclusions In the early pandemic, most children with COVID-19 had a household contact and presented with asymptomatic or mild illness. Severe and critical illness were observed in young infants and those with comorbidities.

Purpose The primary objective of the study was to assess maternal and fetal outcomes of pregnancies affected with dengue fever. Methods This was a prospective, observational and descriptive study carried out over a period of 1 year. 216 pregnant women with fever were screened. Of these, 44 women tested positive for dengue (non-structural protein antigen 1 or dengue IgM antibodies in the sera). The clinical and laboratory characteristics of women with dengue were recorded. Maternal outcomes, pregnancy outcomes and fetal outcomes were studied. Results Mean period of gestation was 31.89 ± 7.31 weeks. Thrombocytopenia was seen in 23 (52.3%) women. Of 40 women, 10 (25%) developed post-partum haemorrhage. The incidence of maternal systemic complications was high: eight (18.2%) women developed acute kidney injury and two (4.5%) required haemodialysis support; eight (18.2%) women developed ARDS and seven (15.9%) women required ventilatory support; four (9.1%) women developed acute liver failure. 18 (40.9%) women had evidence of shock. Seven (15.9%) women died and another seven (15.9%) were classified as WHO maternal near-miss cases. Two (4.5%) pregnancies suffered from miscarriages, four (9%) from still births and two (4.5%) from neonatal deaths. Preterm babies were delivered in 15 (34.1%) and low birth weight babies in 13 (29.5%). Conclusions Dengue in pregnancy adversely affects maternal and fetal outcomes with high maternal mortality of 15.9%. Prematurity and postpartum haemorrhage are significant risks to mother and baby. Vector control strategies should be implemented with vigour in affected areas.

Background and aims Patients with diabetes mellitus (DM) often demonstrate impaired antibody response to influenza/hepatitis B vaccines. Hence, we compared anti-SARS-CoV-2 antibody response in non-severe COVID-19 patients with and without type 2 diabetes mellitus (T2DM). Methods Records of non-severe COVID-19 patients admitted at our institution between April 10, 2020 and May 20, 2020 were retrieved. Qualitative detection of total (IgG + IgM) anti-SARS-CoV-2 antibody was performed using electrochemiluminescence immunoassay in plasma samples collected at least 14 days post-polymerase chain reaction (PCR) confirmation of diagnosis. Results Thirty-one non-severe COVID-19 patients were included. Nine patients (29%) had T2DM with mean HbA1c at admission of 8.3 ± 1.0%. Anti-SARS-CoV-2 antibody was estimated at a median of 16 (14–17) days post-PCR confirmation of COVID-19 diagnosis. Only three patients (10%) were seronegative, and all had T2DM. Patients with T2DM were more likely to have non-detectable anti-SARS-CoV-2 antibodies than those without DM (p = 0.019). Conclusions COVID-19 patients with T2DM may not undergo seroconversion even after two weeks of diagnosis. Impaired seroconversion could theoretically increase the risk of reinfections in patients with DM. However, the finding requires validation in large-scale studies involving serial estimations of anti-SARS-CoV-2 antibodies in patients with and without DM., Highlights • Non-severe COVID-19 patients with T2DM were more likely to be seronegative for anti-SARS-CoV-2 antibodies. • Seronegative patients had higher HbA1c and longer duration of T2DM than seropositive patients. • Absence of anti-SARS-CoV-2 antibodies might increase the risk of reinfections in patients with T2DM.

Guillain- Barre Syndrome (GBS), an autoimmune neurological disease of peripheral nerves has been causally associated with COVID-19 vaccination in adults. However, no such report has been published so far in children. We describe a 13-year old female child who presented to emergency department with complaints of bilateral upper limb, lower limb and truncal weakness over three days following first dose of recombinant protein subunit COVID-19 vaccine (Corbevax). Clinical examination and nerve conduction studies showed pure motor axonal polyneuropathy with absent compound muscle action potential (CMAP) in all sampled nerves of upper and lower limbs which was consistent with the diagnosis of GBS after ruling out possible alternative aetiologies. A temporal association between first dose of protein subunit COVID-19 vaccine administered a day prior and symptom onset was noted. The causality assessment using World Health Organization (WHO) tool for adverse event following immunization (AEFI) assessment indicated vaccine-product related reaction categorized as A1. Patient’s clinical condition improved after seven sessions of plasmapheresis. The purpose of this report is to create awareness among the health care professionals about COVID-19 vaccine induced GBS in children as early diagnosis and management can be critical in avoiding complications and improving patient outcomes.

Environmental surfaces are potential source of SARS-CoV2 transmission. The study assessed the efficacy of hospital disinfection policy and contamination of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) RNA in COVID management Hospital. Inanimate surfaces from both patient areas (n = 70) and non-patient areas (n = 39) were sampled through surface swabbing and subjected to Reverse transcriptase PCR. Out of the 70 samples collected from the COVID hospital, SARS-CoV2 RNA positivity of 17.5% (7/40) and 6.7% (2/30) was seen in high risk and moderate risk area respectively. Samples from Non COVID related patient area such as CD ward and administrative block were assessed and the SARS CoV-2 RNA positivity was 0% and 10% respectively. Among the total 8 environmental surface samples positive for SARS-CoV2 RNA detected from the area surrounding the SARS-CoV2 infected patients, maximum positivity of 31.8% (7/22) was found among the environmental samples collected around the patients with 20 Ct value in nasopharyngeal swab samples followed by 3.3% positivity (1/30) around patients with Ct value ranging from 20 to 25 whereas no SARS-CoV2 RNA (0/5) was detected around the patient with 25 Ct value. Nearly 50% (2/4) of the surface samples came positive from the resident PPE and mobile of the treating doctors which largely elaborates the need for stringent doffing measurement and hand hygiene policy post doffing. The study emphasizes the necessity of frequent and aggressive disinfection policy to prevent nosocomial infection in such high risk areas within close vicinity of the patients.

Renal Doppler to assess renal resistive index (RRI) is an attractive option to prognosticate acute kidney injury (AKI) in acute pancreatitis (AP) as it is feasible within scope of point-of-care ultrasound. However, RRI has been infrequently evaluated in AP.Prospectively study diagnostic and prognostic performance of RRI in patients with AP.75 patients with AP were prospectively enrolled and followed till recovery/death. All patients were subjected to renal Doppler and RRI was compared between patients with and without AKI.Thirty six patients developed AKI and 39 patients did not develop AKI. AKI network stage 1, 2 and 3 AKI was seen in 7(19.4%), 12(33.3%) and 17 (47.2%) patients respectively. Prognostic scoring done at admission by SIRS, modified marshal score, and BISAP scores, as well as duration of hospitalization and mortality rates were significantly higher in patients with AKI. Mean peak systolic velocity and RRI at upper, middle and lower poles of bilateral kidneys were comparable between patients with and without AKI. The RRI was abnormal in 46 (66.6%) patients and it was0.6 in 35/46 (76%) and0.7 in 11/46 (24%) patients respectively. RRI0.6 was observed in 16 (53.3%) and 19 (48.7%) patients with and without AKI respectively (p = 0.80). RRI0.7 was observed in 4 (53.3%) and 7 (48.7%) patients with and without AKI respectively (p = 0.74).AKI is associated with poor prognosis in AP. RRI on renal Doppler at admission seems to have poor diagnostic as well as prognostic performance for AKI in patients with AP.

Medications studied for therapeutic benefits in coronavirus disease 2019 (COVID-19) have produced inconclusive efficacy results except for steroids.A prospective randomized open-label, parallel-arm Phase I/II clinical trial was planned to compare essential oil (EO) blend versus placebo nebulization in mild COVID-19.A Phase I safety evaluation was carried out in a single ascending and multiple ascending dose study designs. We assessed Phase II therapeutic efficacy on COVID-19 and general respiratory symptoms on days 0, 3, 5, 7, 10, and 14 on the predesigned case record form. Viremia was evaluated on day 0, day 5, and day 10.Dose-limiting toxicities were not reached with the doses, frequencies, and duration studied, thus confirming the formulation's preliminary safety. General respiratory symptoms (p 0.001), anosmia (p 0.05), and dysgeusia (p 0.001) benefited significantly with the use of EO blend nebulization compared to placebo. Symptomatic COVID-19 participants with mild disease did not show treatment benefits in terms of symptomatic relief (p = 1.0) and viremia clearance (p = 0.74) compared to the placebo. EO blend was found to be associated with the reduced evolution of symptoms in previously asymptomatic reverse transcription polymerase chain reaction (RT-PCR)-positive study participants (p = 0.034).EO nebulization appears to be a safer add-on symptomatic relief approach for mild COVID-19. However, the direct antiviral action of the EO blend needs to be assessed with different concentrations of combinations of individual phytochemicals in the EO blend.

Although hydroxychloroquine (HCQ) lacks benefit in patients with moderate-to-severe COVID-19, its role in asymptomatic and mildly symptomatic disease needs better elucidation.This multi-centre cohort study included asymptomatic and mildly symptomatic, RT-PCR confirmed COVID-19 cases between 30 March and 20 May, 2020. Patients were categorized into two groups (HCQ-treated and untreated) based on exposure to HCQ. Dose of HCQ used was 400 mg twice daily (day one) followed by once daily for seven days. HCQ-untreated patients were managed supportively without any active antiviral or immunomodulatory therapy. Nasopharyngeal SARS-CoV-2 clearance by RT-PCR (primary outcome) was compared between HCQ-treated and untreated patients using Kaplan-Meier analysis and Cox proportional-hazards regression. Clinical efficacy and safety profile of HCQ were assessed (secondary outcomes).162 patients [84 (51·9%) males; mean age 38·2 (15·2) years] were included. Forty-four (27·2%) patients had mild disease, rest 118 (72·8%) were asymptomatic. Seventy-five (46·3%) patients received HCQ. Median time to virological negativity was lesser in HCQ-treated (13 days) versus untreated patients (15 days) (logranklt;0·001) in both asymptomatic and mildly symptomatic patients. Treatment with HCQ was the only independent predictor of virological negativity (hazardratio=2·24; adjusted p-valuelt;0·001). Two (5·4%) mildly symptomatic patients progressed to severe disease within 24 hours (two doses) of HCQ initiation, compared to none in the HCQ-untreated group. Five HCQ-treated patients developed minor gastrointestinal side effects, not requiring drug discontinuation.HCQ reduced the time to virologic negativity (by 2 days) in asymptomatic and mildly symptomatic COVID-19, without any serious adverse events. However, no obvious clinical benefit was noted.

Objective: Bacterial co-pathogens are common in various viral respiratory tract infections, leading to increased disease severity and mortality. Still, they are understudied during large outbreaks and pandemics. This study was conducted to highlight the overall burden of these infections in COVID-19 patients admitted to our tertiary care hospital, along with their antibiotic susceptibility patterns. Material and methods: During the six-month study period, clinical samples (blood samples, respiratory samples, and sterile body fluids, including cerebrospinal fluid [CSF]) of COVID-19 patients with suspected bacterial coinfections (at presentation) or secondary infections (after 48 hours of hospitalization) were received and processed for the same. Results: Clinical samples of 814 COVID-19 patients were received for bacterial culture and susceptibility. Out of the total patient sample, 75% had already received empirical antibiotics before the samples were sent for analysis. Overall, 17.9% of cultures were positive for bacterial infections. Out of the total patients with bacterial infection, 74% (108/146) of patients had secondary bacterial infections (after 48 hours of hospitalization) and 26% (38/146) had bacterial coinfections (at the time of admission). Out of the 143 total isolates obtained, the majority (86%) were gram-negative organisms, of which Acinetobacter species was the commonest organism (35.6%), followed by Klebsiella pneumoniae (18.1%). The majority (50.7%) of the pathogenic organisms reported were multidrug resistant. Conclusion: The overall rate of secondary bacterial infections (SBIs) in our study was lower (7.9%) than reported by other studies. A rational approach would be to adhere to the practice of initiating culture-based guidance for antibiotics and to restrict unnecessary empirical antimicrobial therapy.

Gastrointestinal (GI) manifestations have been well documented in patients with coronavirus disease 2019 (COVID-19), but its clinical impact on the course of the disease is debatable. Majority of the available data is retrospective, and hence this prospective study was planned to study the impact of GI symptoms on COVID-19 outcome.All COVID-19 patients admitted in a tertiary care centre from August-October 2020 were screened and patients without pre-existing GI diseases were included. A detailed history of the various symptoms including duration was documented. Various baseline laboratory investigations and inflammatory markers were conducted as per the protocol. Patients with and without diarrhea were compared for the various disease outcome parameters.Of the 244 patients screened, 203 patients (128 males; 63.1%) were included. Respiratory symptoms alone were present in 49 (24.1%), GI symptoms alone in 20 (9.9%) and 117 (57.6%) had both. Overall GI symptoms was noted in 137 (67.5%) cases with the commonest being diarrhea (61; 30.0%). Patients with both respiratory and any GI symptoms showed a lower trend towards need for mechanical ventilation (12.2% vs 7.7%; p ​= ​0.35) and mortality (10.2% vs 4.3%; p ​= ​0.14) compared to respiratory symptoms alone, although not statistically significant. Patients with diarrhea (n ​= ​61) had no mortality (0% vs 7.7%; p ​= ​0.036) or need for mechanical ventilation and shorter hospital stay compared to those who did not have diarrhea.GI symptoms are frequent in patients with SARS-CoV-2 infection and the commonest is diarrhea. Diarrhea is a harbinger of better outcome with lower mortality among COVID-19 positive patients.

Background Coronavirus-2019 (COVID-19) patients admitted to the intensive care unit (ICU) have mortality rates between 30%-50%. Identifying patient factors associated with mortality can help identify critical patients early and treat them accordingly. Patients and methods In this retrospective study, the records of patients admitted to the COVID-19 ICU in a single tertiary care hospital from April 2020 to September 2020 were analysed. The clinical and laboratory parameters between patients who were discharged from the hospital (survival cohort) and those who died in the hospital (mortality cohort) were compared. A multivariate logistic regression model was constructed to identify parameters associated with mortality. Results A total of 147 patients were included in the study. The age of the patients was 55 (45, 64), median (IQR), years. At admission, 23 (16%) patients were on mechanical ventilation and 73 (50%) were on non-invasive ventilation. Sixty patients (40%, 95% CI: 32.8 to 49.2%) had died. Patients who died had a higher Charlson comorbidity index (CCI): 3 (2, 4) vs. 2 (1, 3), p = 0.0019, and a higher admission sequential organ failure assessment (SOFA) score: 5 (4, 7) vs. 4 (3, 4), p < 0.001. Serum urea, serum creatinine, neutrophils on differential leukocyte count, neutrophil to lymphocyte ratio (N/L ratio), D-dimer, serum lactate dehydrogenase (LDH), and C-reactive protein were higher in the mortality cohort. The ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, platelet count, lymphocytes on differential leukocyte count, and absolute lymphocyte count was lower in the mortality cohort. The parameters and cut-off values used for the multivariate logistic regression model included CCI > 2, SOFA score > 4, D-dimer > 1346 ng/mL, LDH > 514 U/L and N/L ratio > 27. The final model had an area under the curve of 0.876 (95% CI: 0.812 to 0.925), p < 0.001 with an accuracy of 78%. All five parameters were found to be independently associated with mortality. Conclusions CCI, SOFA score, D-dimer, LDH, and N/L ratio are independently associated with mortality. A model incorporating the combination of these clinical and laboratory parameters at admission can predict COVID-19 ICU mortality with good accuracy.

SARSCoV-2, a coronavirus that causes COVID-19, is spreading rapidly. By the middle of August-2021, it has affected over 3 million confirmed cases in India. The main aim of this study was to examine the clinical profile of COVID-19 patients and their length of stay during treatment in a hospital.It was a hospital-based retrospective study conducted by using a total enumeration technique in July-August 2021 at Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER) in India. The present study was conducted on 72 COVID-19 patients who took treatment in 4C and 5C wards. Structured questionnaires were used to collect data, which included bio-demographic factors and questions about their treatment and length of stay.The majority of the 72 COVID-19 positive patients were men (62%), belonged to the age group of 41-60 years (35%), had SpOTo avoid panic situations, regular admission and discharge of patients was essential due to the considerable increase in cases during the second wave. Patient length of stay was reduced as a consequence of collaboration and cooperation among all physicians, residents, staff nurses, and paramedics, with the goal of discharging the patient after a room air trial and follow up if needed.

COVID-19–associated pulmonary mucormycosis (CAPM) has higher mortality compared with nonpulmonary COVID-19 mucormycosis. The most common CT findings seen in CAPM are consolidation and cavitation.

Background WHO has declared the COVID-19 as Pandemic on 11th March, 2020. It is important to break the chain of transmission by quarantining the persons with high-risk exposure. Understanding the reasons for quarantine will help in reducing the exposures and thus reducing the chances of quarantine. Methods A validated risk assessment tool based on National Centre for Disease Control guidelines was used for the risk assessment of HCWs. The forms of HCWs who underwent risk assessment between April-November, 2020 were analyzed for reasons of quarantine. The positivity rates among high-risk and low-risk groups were compared. Results Out of 1414 HCWs who were assessed, 345 were categorized as high-risk exposure and were quarantined. The most common reasons for quarantine were performance of aerosol generating procedure without recommended personal protection equipment (PPE) (34%), exposure to COVID-19 positive patient without mask for more than 20 minutes at the distance less than 1 m (30%) and having food/tea together (27%). The positivity rate was 8.4% among high-risk and 1.9% among low-risk exposure group (p-value: Conclusion Not using recommended PPE and having tea/food breaks together were the most common reasons for quarantine. Key messages Strict enforcement of recommended PPE and scattered tea and food breaks can reduce high-risk exposures.