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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.

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%.

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 Hydroxychloroquine (HCQ) was one of the earliest drugs to be recommended for tackling the COVID-19 threat leading to its widespread usage. We provide preliminary findings of the system, established in a tertiary care academic center for the administration of HCQ prophylaxis to healthcare workers (HCW) based on Indian Council of Medical Research (ICMR) advisory. Methods A dedicated clinical pharmacology and internal medicine team screened for contraindications, administered informed consent, maintained compliance and monitored for adverse events. Results Among the 194 HCWs screened for ruling out contraindications for prophylaxis, 9 were excluded and 185 were initiated on HCQ. A total of 55 adverse events were seen in 38 (20.5%) HCWs out of which 70.9%, 29.1% were mild and moderate & none were severe. Before the completion of therapy, a total of 23 participants discontinued. Change in QTc interval on day 2 was 5 (IQR: −3.75, 11) ms and the end of week 1 was 15 ms (IQR: 2, 18). Out of the 5 HCW who turned positive for COVID-19, 2 were on HCQ. Conclusion HCQ prophylaxis was found to be safe and well tolerated in HCW when administered after appropriate screening and with monitoring for adverse events.

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.

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.

The current pandemic coronavirus, SARS-CoV-2, is known to cause severe infection (COVID-19) in patients with comorbidities, particularly cancer or an immunosuppressed state. Most healthcare systems in the country are likely to be overwhelmed soon if the pandemic moves to a stage of community transmission. Currently, limited evidence is available for managing patients with hematological disorders during the COVID-19 pandemic. The current review summarises the possible challenges clinicians are likely to face, key considerations to guide decision making, and possible solutions to the anticipated challenges. Disease specific recommendations and possible guidance for decision making have been suggested for most hematologic diseases that are feasible in our health setup. It is not meant to replace individual clinical judgment, but to provide a template to formulate local policies.

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.

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.

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.

INTRODUCTION There is a close association between the use of broad-spectrum antibiotics, gut microbiome alteration, multidrug resistant (MDR) gram-negative bacilli (GNB) bacteremia, graft versus host disease (GVHD), and mortality post-allogeneic hematopoietic cell transplantation (allo-HCT). This study reports the impact of the high use of carbapenems and colistin and MDR bacteremia pre- and post-HCT on HCT outcomes. METHODS This was a single-center, partial retrospective, and prospective study from 2016 to 2020. Both pre- and post-HCT antibiotic exposures and blood culture/sensitivity were recorded. MDR GNB was defined as either non-susceptibility to third-generation cephalosporin or carbapenems. In the absence of positive cultures, the treating physician escalated antibiotics from third-generation cephalosporins to carbapenem and/or colistin as per clinical discretion. De-escalation policy was not strictly enforced. RESULTS MDR GNB bacteremia was seen in 29 of 76 (38%) of patients peri-HCT. The utilization rates for carbapenems and colistin was significantly higher in the cohort with MDR GNB bacteremia pre-HCT (70% vs. 32%, p = 0.002 and 31% vs. 6.4%, p = 0.007, respectively) and post-HCT (100% vs. 74.5%, p = 0.002, and 55.2% vs. 8.5%, p

IntroductionEvidence on new-onset endocrine dysfunction and identifying whether the degree of this dysfunction is associated with the severity of disease in patients with COVID-19 is scarce.Patients and MethodsConsecutive patients enrolled at PGIMER Chandigarh were stratified on the basis of disease severity as group I (moderate-to-severe disease including oxygen saturation 94% and without comorbidities) (n=49). Hypothalamo-pituitary-adrenal, thyroid, gonadal axes, and lactotroph function were evaluated. Inflammatory and cell-injury markers were also analysed.ResultsPatients in group I had higher prevalence of hypocortisolism (38.5 vs 6.8%, p=0.012), lower ACTH (16.3 vs 32.1pg/ml, p=0.234) and DHEAS (86.29 vs 117.8µg/dl, p= 0.086) as compared to group II. Low T3 syndrome was a universal finding, irrespective of disease severity. Sick euthyroid syndrome (apart from low T3 syndrome) (80.9 vs 73.1%, p= 0.046) and atypical thyroiditis (low T3, high T4, low or normal TSH) (14.3 vs 2.4%, p= 0.046) were more frequent in group I than group II. Male hypogonadism was also more prevalent in group I (75.6% vs 20.6%, p=0.006) than group II, with higher prevalence of both secondary (56.8 vs 15.3%, p=0.006) and primary (18.8 vs 5.3%, p=0.006) hypogonadism. Hyperprolactinemia was observed in 42.4% of patients without significant difference between both groups.ConclusionCOVID-19 can involve multiple endocrine organs and axes, with a greater prevalence and degree of endocrine dysfunction in those with more severe disease.

Background This study was performed to investigate the presence of SARS-CoV-2 virus in wounds of COVID-19 positive patients. Methods This is a single-center observational study. COVID-19 patients with wounds (traumatic/infective/surgical) were included in this study. Preoperative, intraoperative, or postoperative specimens were collected and analyzed with real-time reverse transcriptase polymerase chain reaction (rRT-PCR) to know the presence of the virus. Results A total of eight patients were included in this study. Eleven samples were collected (seven wound swabs, two peritoneal fluids, and two tissue specimens) and analyzed. None of the samples from the wound tested positive for the virus while they were tested positive for nasal swab taken simultaneously or within 3 days prior. Conclusion The wounds of COVID-19 patients are considered negative and can be managed with routine wound precautions.

The recently discovered SARS-CoV2 virus produces a influenza like illness named Coronavirus disease 2019 (COVID-19). The usual presentation is with upper/lower respiratory tract symptoms and rarely gastrointestinal symptoms. Although some of the clinical features of this novel disease like fever, dry cough, and shortness of breath have been well documented in literature, we report hitherto infrequently reported clinical features of this disease, namely Anosmia and Ageusia.

Acute acalculous cholecystitis is usually seen in association with systemic medical illness, or after surgery, trauma or burn and is considered as a more severe disease than acute calculous cholecystitis. We recently had the opportunity of observing a patient who was admitted in a surgical emergency with clinical features of acute cholecystitis and was found to have Orientia tsutsugamushi infection after a strong clinical suspicion of acute tropical fever illness.

The Marburg I polymorphism (G511E) in FSAP gene was listed as one of the risk factor for idiopathic DVT among the western population. The frequency of Marburg I polymorphism in India is presently not known. Fifty DVT cases and 50 healthy controls were tested for Marburg I polymorphism using ARMS-PCR technique. The thrombophilic risk factors (Protein C, Protein S, Antithrombin III, Factor V Leiden and antiphospholipid antibodies) were also determined. Marburg I polymorphism (heterozygous) was found in 2 patients (4%) but not in control subjects. These two cases did not have any other thrombophilia markers. Among the thrombophilic markers, heterozygous FVL mutation, PS, PC, AT deficiencies and antiphospholipid antibodies were seen in 10%, 10%, 6%, 6% and 8% of the patients respectively. The controls showed only the presence of antiphospholipid antibodies in 6% of subjects. Marburg I polymorphism among Indians DVT patients was determined for the first time. Its incidence was found in 4% of cases and not in controls. Although not statically significant this may be considered as one of the contributory risk factors for the development of DVT. A larger study is required for the validation of data.

Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening.Methods: In a prospective, cross-sectional, observational study (July–November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, “hospitalized” patients (73) were screened at least 2 weeks after hospital discharge, and “home-isolated” patients (20) were screened 17 days after symptom onset/COVID-19 testing.Results: None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis.Conclusions: CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase. These patients were much older (median age = 69 years) than the average age of our sample and had systemic comorbidities (diabetes mellitus, hypertension, etc.). We propose the term “COVID-19 retinopathy” to denote the presence of CWSs at the posterior pole, occasionally associated with intraretinal hemorrhages, in the absence of ocular inflammation in patients with a history of COVID-19 disease.

Introduction The role of pre-HCT chest high resolution computed tomography (HRCT) and serum galactomannan index (GMI) in predicting the post-allogeneic hematopoietic cell transplant (HCT) invasive pulmonary aspergillosis (IPA) is debatable. Methods This was a single-center, prospective study from 2014-2019. The primary objective was to study if pre-HCT chest HRCT and serum GMI predicted IPA post-HCT. The secondary objective was day +100 mortality. All consecutive, consenting patients of ≥ 12 years of age undergoing allo-HCT were included and had pre-HCT chest HRCT and serum GMI. All patients received mold active antifungal prophylaxis. The EORTC/ MSG criteria were used for the diagnosis of IPA. Results A total of 82 patients with median age 27 years (12-59 years) were included. The. underlying diagnoses included hematological malignancies (79%) and aplastic anemia (21%). 15% of patients were treated for prior history of probable IPA (> 6-weeks before HCT). Pre-HCT chest HRCT satisfied EORTC clinical criteria in 24% patients. Serum GMI ≥ 0.5 was seen in 27% of patients. Post-HCT probable IPA was seen in 24% of patients. There were more patients with pre-HCT chest HRCT findings satisfying EORTC clinical criteria (45% vs. 18%, p = 0.014) and GMI ≥0.5 (45% vs. 21%, p = 0.03) in the group with post-HCT IPA compared to those without IPA. There was higher day+100 mortality in patients with post-HCT IPA (55% vs. 18%, p = 0.001). Conclusions The presence of EORTC clinical criteria on pre-HCT chest HRCT, serum GMI ≥ 0.5 and prior history of IPA predicted post-HCT IPA.

Background The crisis of critical care resource allocation during the novel coronavirus infectious disease 2019 (COVID-19) pandemic has underscored the importance of triage. COVID-19 is associated with increased hypoxemia and desaturation on exertion. We hypothesized that desaturation after 1-min sit-to-stand test (1MSTS), a validated field exercise test can serve as a potential marker for triage of COVID 19 patients. Methods Subjects with proven COVID 19 without hypoxemia on ambient air at presentation underwent the 1MSTS. The demographic details, clinical profile, pre and post-test vitals and pulse oximetric saturation was recorded and they were followed up for outcome throughout the hospital stay and after discharge. Results 55 mild cases of COVID-19 and 6 cases of recovering severe COVID-19 were included. The mild cohort had a median age of 35 years (IQR, 27–41.5) and a median hospital stay of 16 days (IQR 14,20). The severe cohort had a median age of 47.5 years (IQR, 42.3,54.3) and median intensive care and hospital stays of respectively 9 (IQR, 7.5,9) and 23.5 (IQR, 21.5,27) days. The two cohorts showed median desaturations of 0% (IQR, 0.5–1) and 5.5% (IQR, 4.3–6) respectively. No subjects in the mild cohort needed oxygen therapy or escalation of care to intensive care. Conclusions Significant desaturation after 1-MSTSin severe COVID 19 patients demonstrates the potential role of 1-MSTS both in triage for planning care and as a discharge criteria from intensive care unit. However, larger prospective studies are warranted for its evaluation and establishment of relevant cut-offs.

COVID-19 is an ongoing pandemic with many challenges that are now extending to its intriguing long-term sequel. ‘Long-COVID-19ʹ is a term given to the lingering or protracted illness that patients of COVID-19 continue to experience even in their post-recovery phase. It is also being called ‘post-acute COVID-19ʹ, ‘ongoing symptomatic COVID-19ʹ, ‘chronic COVID-19ʹ, ‘post COVID-19 syndrome’, and ‘long-haul COVID-19ʹ. Fatigue, dyspnea, cough, headache, brain fog, anosmia, and dysgeusia are common symptoms seen in Long-COVID-19, but more varied and debilitating injuries involving pulmonary, cardiovascular, cutaneous, musculoskeletal and neuropsychiatric systems are also being reported. With the data on Long-COVID-19 still emerging, the present review aims to highlight its epidemiology, protean clinical manifestations, risk predictors, and management strategies. With the re-emergence of new waves of SARS-CoV-2 infection, Long-COVID-19 is expected to produce another public health crisis on the heels of current pandemic. Thus, it becomes imperative to emphasize this condition and disseminate its awareness to medical professionals, patients, the public, and policymakers alike to prepare and augment health care facilities for continued surveillance of these patients. Further research comprising cataloging of symptoms, longer-ranging observational studies, and clinical trials are necessary to evaluate long-term consequences of COVID-19, and it warrants setting-up of dedicated, post-COVID care, multi-disciplinary clinics, and rehabilitation centers., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/rSFlP8bHkX0

A 15-year-old Indian girl presented with fever and involuntary movements of the limbs and face of about a weeks’ duration. These stereotypic choreoathetosis movements involved both upper limbs, lower limbs and face (figure 1A,B; video 1). No other neurological deficits were noted and cardiorespiratory, abdominal examinations were normal. Figure 1 (A) Chorea of the tongue causing darting in and out movements (B) Involuntary, non-patterned and purposeless movements of upper limbs. Video 1 Evaluation revealed bicytopenia with neutrophilic leucocytosis. Blood cultures were sterile and cerebrospinal fluid analysis was unremarkable including herpes simplex virus—PCR, Venereal …

IntroductionHealth care workers (HCWs) are at the forefront to fight against COVID-19 pandemic. They are at more risk of contracting the infection. This study was planned to assess potential risk factors of 2019-novel coronavirus infection among HCWs working in a health facility and to evaluate the effectiveness of infection prevention and control measures among them.MethodsA study was conducted in a tertiary care hospital among HCWs who were directly or indirectly involved in the management of a confirmed or suspected case of COVID-19. The socio-demographic characteristics, history of exposure, IPC measures followed and clinical symptoms were compared between health care workers in COVID and non-COVID areas.ResultsMajority (45%) of HCWs were nurses, followed by hospital/sanitary/technical attendants (30%) and doctors (24%). Out of a total of 256 HCWs, 2% tested positive. Around 80% of HCWs had ever attended any IPC training. A statistically significant association was found between posting area of HCWs and their exposure to COVID patients (duration of exposure, PPE has worn by HCWs, direct contact of HCWs with the patient’s material) and COVID positivity ( P value ConclusionIf health care workers were trained and take adequate precautions then the risk of getting an infection is minimized.

ObjectivesHealthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty.SettingOur tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless.ParticipantsWe recruited willing low-risk HCP, aged ResultsBetween 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (ConclusionA multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.

Background: The correlation of SARS-CoV-2 viral load with disease severity in different population subsets is still elusive. There is a scarcity of literature regarding this aspect in Indian Population. Aim: To study retrospectively the risk factors and the role of viral load with disease severity among different age groups of North Indian population. Methods: Here we quantified the viral load of 239 positive participants and collected data retrospectively from April 2020 to May 2020 and categorised the patients as per disease severity and population subsets. Results: Asymptomatic patients were found to have higher viral load than the symptomatic patients, though the difference was not found to be statistically significant. The logistic regression analysis showed that contact with laboratory confirmed cases, SARI and ILI were independent risk factors for acquiring COVID-19 infection. Conclusion: SARS-CoV-2 viral load is not significantly associated with disease severity among different population subsets. However, there is a need to carry out more studies with a larger number of patients to validate and confirm the above findings.

A “superspreader” refers to an unusually contagious organism infected with a disease. With respect to a human borne illnesses, a superspreader is someone who is more likely to infect other humans when compared to a typically infected person. The existence of human superspreaders is deeply entrenched in history; the most famous case being that of Typhoid Mary. Through contact tracing, epidemiologists have identified human superspreaders in measles, tuberculosis, rubella, monkeypox, smallpox, Ebola hemorrhagic fever, and SARS. The recent outbreak of Coronavirus disease (COVID-19) has shifted the focus back on the superspreaders. We herein present a case report of a COVID-19 superspreader with a hitherto unusually high number of infected contacts. The index case was a 33 year old male who resided in a low income settlement comprising of rehabilitated slum dwellers and worked as a healthcare worker (HCW) in a tertiary care hospital and had tested positive for COVID-19.On contact tracing, he had a total of 125 contacts, of which 49 COVID-19 infections had direct or indirect contact with the index case, qualifying him as a “superspreader.” This propagated infection led to an outbreak in the community. Contact tracing, testing and isolation of such superspreaders from the other members of the community is essential to stop the spread of this disease and contain the COVID-19 pandemic.

Purpose: To compare serum total calcium and phosphate levels in patients with non-severe COVID-19 with age, sex, and serum 25-hydroxyvitamin D level matched healthy adult cohort.Methods: In this retrospective case-control study, medical records of patients (≥18 years) diagnosed as non-severe COVID-19 admitted at and discharged from our tertiary care institution during the period from April 10, 2020 and June 20, 2020 were retrieved. Baseline investigations, notably, serum calcium, phosphate, albumin, magnesium, 25-hydroxyvitamin D, and C-reactive protein (CRP), were performed at admission before any form of calcium or vitamin D supplementation were considered. The biochemical parameters were compared with age, sex, and 25-hydroxyvitamin D matched healthy adult controls (1:1 ratio) derived from the Chandigarh Urban Bone Epidemiological Study (CUBES).Results: After exclusion, 72 patients with non-severe COVID-19 (63 mild and 9 moderate disease) and an equal number of healthy controls were included in the final analysis. Age, sex, serum 25-hydroxyvitamin D, and albumin levels were matched between the 2 groups. Hypovitaminosis D and hypocalcemia were seen in 97 and 67% of the patients, respectively. The patients had lower serum calcium (P value P = 0.007) compared with the controls. There was no statistically significant correlation between serum calcium and CRP.Conclusions: Hypocalcemia is highly prevalent even in COVID-19 patients with non-severe disease probably implying that hypocalcemia is intrinsic to the disease. Prospective studies with larger number of patients are required to prove this hypothesis and unravel the underlying pathophysiological mechanisms.

Dear Editor,We read with keen interest the excellent review by Anikhindi et al. regarding the management strategies for inflammatory bowel disease (IBD) in the COVID era [1]. As suggested by the au...

Background & Aims: A procoagulant state with pulmonary micro-thrombosis has been described in COVID-19, which contributes to pathophysiology of respiratory failure along with diffuse alveolar damage. Cytokine storm and systemic inflammation in COVID-19 generates endogenous heparinoids from the endothelium which leads to secondary organ failures. We prospectively studied the dynamic association of the coagulation abnormalities with respiratory failure and mortality in patients with COVID-19. Methods: We did a prospective observational study in adults aged between 18-80 years with COVID 19 pneumonia requiring intensive care (ICU) admissions in a tertiary care hospital in North India. All patients received standard medical therapy based on best available evidence. Patients were categorized based on the oxygen support therapy into low flow, high flow and invasive ventilation groups. In patients considered to be at risk of thromboembolic or bleeding phenomena, paired coagulation tests were performed at days 1 and 3 with, Sonoclot ® (glass beaded and heparinase-treated). All patients were consecutively followed for inflammatory markers, ventilator requirements and survival. Activated clotting time (ACT) 75 units were used as the cut-off for hypercoagulable state. The heparin like effect (HLE) was considered by a correction of ≥ 40 s in hACT (heparinized treated ACT). The trial is registered with ClinicalTrials.gov (NCT04668404). Results: A total of 2324 patients with COVID-19 were screened from August 2020 to November 2020. Two hundred and fifteen patients requiring ICU admission were assessed and 74 patients with a median age of 54(42-67) years were enrolled. A procoagulant profile was seen in 45.5%, 32.4% and 20.7% in low-flow, high-flow, and invasive ventilation. Paired Sonoclot ® assays in 33 patients demonstrated HLE in 17 (51.5%) and 20 (62.5%) at days 1 and 3 respectively. In multivariate analysis, the presence of HLE (HR 1.02; CI 1.08-1.6; p 131 s, clot rate 96.7 mg/l at admission predicted mortality. Conclusions: HLE contributes to hypocoagulable effect, need for invasive ventilation and mortality in patients with COVID-19. Trial Registration: The trial is registered with ClinicalTrials.gov (NCT04668404). Funding Statement: None Declaration of Interests: None Ethics Approval Statement: Ethical clearance was obtained from the Institutional Review Board (PGI/IEC/2020/000997 dated 24 August 2020)

Highlights • Study of the efficacy of hydroxychloroquine (HCQ) as post-exposure prophylaxis (PEP) for prevention of COVID-19. • PEP with HCQ in asymptomatic, high-risk household contacts of laboratory-confirmed COVID-19 cases. • Significant risk reduction for incidence of COVID-19 in participants receiving PEP with HCQ. • Further studies to prove the virucidal effect of HCQ in vivo are required. • Further randomised clinical trials with larger sample sizes are required for better evaluation of HCQ as PEP for prevention of COVID-19., Many drugs have been tried for the treatment/prevention of COVID-19 with limited success. Direct household contacts of COVID-19 patients are at highest risk for SARS-CoV-2 infection. Hydroxychloroquine (HCQ) has been tried against COVID-19 owing to its in vitro virucidal action against SARS-CoV-2, but the role of HCQ as post-exposure prophylaxis (PEP) remains inconclusive. In this open-label, controlled clinical trial, asymptomatic individuals who had direct contact with laboratory-confirmed COVID-19 cases or had undertaken international travel in the last 2 weeks were offered HCQ prophylaxis and assigned to PEP (n = 132) or control (n = 185) group. The PEP group received HCQ 800 mg on Day 1 followed by 400 mg once weekly for 3 weeks. Both groups undertook home quarantine for 2 weeks along with social distancing and personal hygiene. Over 4-week follow-up, 50/317 participants (15.8%) had new-onset COVID-19. The incidence of COVID-19 was significantly (P = 0.033) lower in the PEP (14/132; 10.6%) compared to the control (36/185; 19.5%) group (total absolute risk reduction, –8.9% points). The NNT to prevent the occurrence of 1 COVID-19 case was 12. Overall relative risk was 0.59 (95% CI 0.33–1.05). Compliance was good. The most common adverse event was epigastric discomfort with burning sensation (three participants), with no serious adverse events. PEP with HCQ has the potential for the prevention of COVID-19 in at-risk individuals. Until definitive therapy is available, continuing PEP with HCQ may be considered in suitable at-risk individuals. Further randomised clinical trials with larger samples are required for better evaluation of HCQ as PEP for COVID-19 prevention.

Background Vitamin D has an immunomodulatory role but the effect of therapeutic vitamin D supplementation in SARS-CoV-2 infection is not known. Aim Effect of high dose, oral cholecalciferol supplementation on SARS-CoV-2 viral clearance. Design Randomised, placebo-controlled. Participants Asymptomatic or mildly symptomatic SARS-CoV-2 RNA positive vitamin D deficient (25(OH)D Intervention Participants were randomised to receive daily 60 000 IU of cholecalciferol (oral nano-liquid droplets) for 7 days with therapeutic target 25(OH)D>50 ng/ml (intervention group) or placebo (control group). Patients requiring invasive ventilation or with significant comorbidities were excluded. 25(OH)D levels were assessed at day 7, and cholecalciferol supplementation was continued for those with 25(OH)D Outcome measure Proportion of patients with SARS-CoV-2 RNA negative before day-21 and change in inflammatory markers. Results Forty SARS-CoV-2 RNA positive individuals were randomised to intervention (n=16) or control (n=24) group. Baseline serum 25(OH)D was 8.6 (7.1 to 13.1) and 9.54 (8.1 to 12.5) ng/ml (p=0.730), in the intervention and control group, respectively. 10 out of 16 patients could achieve 25(OH)D>50 ng/ml by day-7 and another two by day-14 [day-14 25(OH)D levels 51.7 (48.9 to 59.5) ng/ml and 15.2 (12.7 to 19.5) ng/ml (p Conclusion Greater proportion of vitamin D-deficient individuals with SARS-CoV-2 infection turned SARS-CoV-2 RNA negative with a significant decrease in fibrinogen on high-dose cholecalciferol supplementation. Trial register number NCT04459247.

ObjectivesConvalescent plasma (CP) as a passive source of neutralizing antibodies and immunomodulators is a century-old therapeutic option used for the management of viral diseases. We investigated its effectiveness for the treatment of COVID-19.DesignOpen-label, parallel-arm, phase II, multicentre, randomized controlled trial.SettingThirty-nine public and private hospitals across India.ParticipantsHospitalized, moderately ill confirmed COVID-19 patients (PaO2/FiO2: 200-300 or respiratory rate > 24/min and SpO2 ≤ 93% on room air).InterventionParticipants were randomized to either control (best standard of care (BSC)) or intervention (CP + BSC) arm. Two doses of 200 mL CP was transfused 24 hours apart in the intervention arm.Main Outcome MeasureComposite of progression to severe disease (PaO2/FiO2< 100) or all-cause mortality at 28 days post-enrolment.ResultsBetween 22ndApril to 14thJuly 2020, 464 participants were enrolled; 235 and 229 in intervention and control arm, respectively. Composite primary outcome was achieved in 44 (18.7%) participants in the intervention arm and 41 (17.9%) in the control arm [aOR: 1.09; 95% CI: 0.67, 1.77]. Mortality was documented in 34 (13.6%) and 31 (14.6%) participants in intervention and control arm, respectively [aOR) 1.06 95% CI: −0.61 to 1.83].InterpretationCP was not associated with reduction in mortality or progression to severe COVID-19. This trial has high generalizability and approximates real-life setting of CP therapy in settings with limited laboratory capacity. A priori measurement of neutralizing antibody titres in donors and participants may further clarify the role of CP in management of COVID-19.Trial registrationThe trial was registered with Clinical Trial Registry of India (CTRI); CTRI/2020/04/024775.

Aim: The aim of this study is to elucidate the demographics, symptoms and outcome of sick persons visiting coronavirus (COVID) screening OPD of a tertiary institute in North India. Study Design: The present descriptive, prospective study was done on 1030 patients and information about presenting symptoms, demographics (age, sex, nationality, residence), contact and travel history, comorbidities etc., were recorded. On the basis of criteria given by Indian Council of Medical Research, patients were divided into suspected (SARS-CoV-2) and non-suspected group. Of the suspected patients, with RT-PCR test positive were classified as confirmed COVID-19 case and negative RT-PCR symptomatic individual were defined as negative COVID-19 case. Results: Out of the total patients, 65.6% were male and 34.4% were females. The mean age was 37.04 years. Fever 49.3%, cough 57.1% and sore throat 43.5% were the main symptoms. Comorbidities were seen in 8.5% patients with hypertension (3.5%) and diabetes mellitus (3.4%). Forty patients were positive. Highly significant correlation (P < 0.01) was found between COVID-19 positive status and in patients without any symptoms, between COVID-19 and cough and sore throat, between COVID-19 and comorbidity (diabetes mellitus), between COVID-19 and high-risk exposures (resident of hot spot and history of contact with confirmed case). Our study also found COVID-19 positive status, shortness of breath and tachycardia as independent predictors of mortality (P < 0.05). Conclusions: Most of the patients were young adults and males were mainly affected. Main presentation was cough followed by fever. Infectivity was higher in patients who had underlying comorbid diseases, especially diabetes and chronic kidney disease. Critical patients with decreased oxygen saturation, tachypnoea and tachycardia had strong predictability for COVID-19 positivity. COVID-19 positive status, shortness of breath and tachycardia are important predictors of mortality.

Background Characteristics of laboratory findings of COVID-19 patients are of great significance for diagnosis and treatment. Studies that have analysed the variations in hepatic profile in correlation with the inflammatory markers in SARS-CoV-2 are limited. Methods We retrospectively analysed liver function tests and inflammatory markers of 170 admitted patients with confirmed COVID-19 in the tertiary care centre, Post Graduate Institute of Medical Education and Research (PGIMER), India, using Roche Cobas Autoanalyzer. Results Number of patients with normal liver enzyme levels were 63 (41.5%), while with raised levels of any of the liver enzymes were 89 (58.5%), out of which 43 (48.31%) had liver injury which manifested as increased severity in terms of intensive care unit (ICU) requirement (p=0.0005). Significantly raised levels of liver enzymes and liver injury were observed with age (p Conclusions More than half of patients admitted to the hospital with SARS-CoV-2 infection had an abnormal liver function which was found to be associated with raised levels of inflammatory markers. Significantly higher proportions of patients with abnormal liver function were elderly and males and were at higher risk of progressing to severe disease.

People living with Human Immunodeficiency Virus (PLHIV) are at greater risk of developing prolonged illness due to COVID 19 leading to longer duration of virus shedding owing to their underlying immune defects. The present study compared SARS-CoV-2 infection developing at the same time among two health care workers living with and without a history of HIV and working in the same ward of a tertiary care hospital of North India. A higher viral load was reported in the SARS-CoV-2 infected worker who was immunocompromised as compared to immunocompetent patient (19,193 copies/µL vs 9.4 copies/µL). In this preliminary case report, no difference was observed in the clinical presentation of both patients at the time of diagnosis. Further studies are required to investigate the COVID-19 susceptibility and severity among HIV-infected patients.

SARS-CoV-2 or COVID-19 pandemic outbreak has been creating havoc and has imposed a sense of severe insecurity and panic like situation (Tandon, 2020a, 2020b). The mass media/telecommunications /newspaper/blogs have been updating the information about the rapid rise in cases leading to admission to the hospital, being kept in the isolation ward, requiring oxygen support, being admitted in intensive care units (ICUs), associated mortality and the fate of the dead bodies (packaging/filled up graveyards/crematorium). All this news has led to a significant fear, anxiety, uncertainty, and restlessness in the general public. In this background, when one is diagnosed with COVID-19 infection, the diagnosis brings, in a feeling of shock and disbelief, and a feeling of being on the death bed. Many a time, the diagnosis not only leads to admission into the hospital but also leads to a diagnosis of COVID-19 infection in other family members, family members being sent to quarantine and other contacts being traced to the person (Sahoo et al., 2020a). Given the high infectivity and reported consequences of infections, including mortality, COVID-19 is known to have significant negative mental health outcomes, not only in those who are diagnosed with the infection and their family members but also in the general public (Wang et al., 2020; Zhao and Huang, 2020) and the front line health care workers (HCWs) (Kang et al., 2020; Lai et al., 2020; Rossi et al., 2020; Tan et al., 2020). Currently, there are viewpoints and perspectives of mental health professionals regarding the different emotional reactions/issues and possible psychiatric problems which may arise in people diagnosed with COVID infection (Grover et al., 2020; Yao et al., 2020). Due to the negative mental health consequences, it is suggested that a mental health professional should be part of the core team managing patients with COVID-19 infection(Grover et al., 2020). Available literature from the previous epidemics of infectious diseases suggests the occurrence of post-traumatic stress disorder, depression, and anxiety disorders in patients admitted with SARS (2002) and Middle East Respiratory Syndrome (MERS, 2012) during the post-illness/recovery stage (Rogers et al., 2020). Further, emerging evidence also suggests the occurrence of delirium (confusion, agitation, altered consciousness) in patients admitted to ICUs with severe COVID-19 infection (Chen et al., 2020; Helms et al., 2020) and neuropsychological deficits (dysexecutive syndrome) at discharge (Helms et al., 2020). However, there is very limited literature on the psychological experience of patients with COVID-19 during their hospital stay. One study (n = 144) reported significant anxiety (34 %) and depression (28 %) at admission to isolation wards (Kong et al., 2020), the other (n = 26) study reported higher anxiety and depressive scores on HAM-A and HAM-D respectively after one week of hospitalization, which decreased after comprehensive psychological interventions (Yang et al., 2020). Another study (n = 57) found prevalence of depression to be around 30 % in newly recovered COVID-19 patients (Zhang et al., 2020). Further, a study with large sample (n = 714) of hospitalised but stable patients with COVID-19 reported post-traumatic stress symptoms in 96.2 % patients (Bo et al., 2020). However, these studies had not explored in detail the emotional reactions which the patients went during the entire period of hospital stay till discharge. We reported the narrative experiences of our patients during their hospital stay, who had significant distress when diagnosed with COVID-19 infection (Sahoo et al., 2020a, 2020b). These experiences of few patients prompted us to evaluate the experience of all the patients, admitted to the COVID-19 ward. In this background, the current study aimed to evaluate the emotional reactions/experiences which the patients go through, while admitted to the COVID-19 ward, at the time of discharge.