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The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4-9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24-6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09-0.42; p

Background: COVID-19 pandemic has taken a great toll on the health care system worldwide. Along with the pandemic, there is also a concern regarding post COVID-19 complications in recovered patients. Thromboembolism (TE) has been reported as a fatal complication in recovered patients with COVID-19. There is still a great dilemma in post-discharge TE prophylaxis and its long-term benefits. Case Description: We reported three cases of post COVID-19 with complications related to both diseases as well as post discharge anticoagulant therapy. The first case is about a 60-yr-old male who developed Covid-19 pneumonia (moderate disease) and was discharged on rivaroxaban after initial improvement. 3 weeks later, the patient was readmitted with lower gastro-intestinal bleeding. The other two cases developed pulmonary thromboembolism within a span of 2-3 months (after recovered from COVID-19 pneumonia). Both these patients were not prescribed anticoagulants for TE prophylaxis. Conclusion: There is an imperative need for effective guidelines for post discharge TE prophylaxis in COVID-19.

Background: Dengue fever is an arthropod-borne viral infection with a very high incidence rate in Southeast Asia. Most patients present with self-limiting febrile illness, while some patients may develop complications like acute kidney injury, acute liver failure, myocarditis or Guillain– Barre syndrome. The coexistence of Dengue and MRSA (Methicillin-resistant Staphylococcus aureus ) is rarely reported in the literature. Case: A 28-year-old male is presented with high-grade fever, polyserositis and thrombocytopenia. The patient was treated symptomatically for dengue infection. During the course of hospitalization, patient developed neck swelling (thyroid abscess) and left forearm abscess. MRSA was isolated from blood culture and pus, and successfully treated with iv antibiotics (Vancomycin). Conclusion: High anticipation and vigilance are required to detect concurrent bacteremia in dengue patients. Early recognition of warning signs with readily antibiotic therapy is important to prevent mortality and morbidity in these patients. Our report also highlights the MRSA as a rare cause of thyroid abscess, with only 5 cases reported in the literature so far.

Gastrointestinal involvement in systemic lupus erythematosus (SLE) usually occurs in the form of mesenteric vasculitis, protein-losing enteropathy, intestinal pseudo-obstruction, and pancreatitis. We describe a 23-year-old female, a known case of SLE presented with significant ascites and pleural effusion. Further evaluation showed elevated CA-125 levels without evidence of malignancy. The patient was treated with corticosteroids, hydroxychloroquine, and azathioprine resulting in the resolution of ascites in 2 weeks. The triad of ascites, pleural effusion, and increased CA-125 is known as pseudo-pseudo Meigs' syndrome, which is rarely reported in the literature. Clinicians should be aware of this entity while evaluating an SLE patient with low serum-ascites albumin gradient (SAAG) ascites.

Progressive disseminated histoplasmosis (PDH) usually presents as fever, anemia, leukopenia, hepatosplenomegaly, lymphadenopathy and pulmonary symptoms. There are few reports showed the association of Idiopathic CD4 lymphocytopenia (ICL) with histoplasmosis. We describe a 65-year-old female presented with history of fever, papulo-nodular rash and significant weight loss and diagnosed as progressive disseminated histoplasmosis. All immunocompromised conditions were ruled out. In addition, her 2 consecutive CD4 counts were below 300. The patient was diagnosed with PDH associated with ICL. Patient showed significant improvement with liposomal amphotericin B and itraconazole. Absolute CD4 counts should be done in all cases of progressive disseminated histoplasmosis even in HIV negative individuals to rule out associated ICL.

Background Bloodstream infections (BSIs) are an emerging cause of significant morbidity and mortality in severe Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence, clinical profile and outcome of BSIs in critically ill COVID-19 patients. Methods This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age > 18 years) with reverse-transcription polymerase chain reaction (RT-PCR) confirmed COVID-19 admitted in the intensive care unit (ICU) were included. Hospital electronic records were searched for demographic data, time of bloodstream infection since admission, clinical profile, antimicrobial resistance pattern and clinical outcome of all patients who developed BSIs. Results Out of 750 patients admitted in COVID ICU, 8.5% developed secondary BSIs. All severe COVID-19 patients who developed BSIs succumbed to illness. A significant proportion of BSIs were Gram-negative pathogens (53/64, 82.8%). Acinetobacter baumannii was the commonest isolate, followed by Klebsiella pneumoniae (32.8% and 21.9%, respectively). Multidrug-resistance organisms (MDRO) were found in 57.8% of the cases. The majority of MDRO belonged to K. pneumoniae and Enterococcus groups. The proportion of Gram-negative bacteria resistant to carbapenems was 47.2% (25/53). On multivariate analysis, raised total leukocyte counts, mechanical ventilation and presence of comorbidities were significantly associated with the incidence of BSIs. Conclusion We found a significant prevalence of Acinetobacter baumannii in COVID-19 associated BSIs. The presence of comorbidities raised leukocyte counts and mechanical ventilation should alarm clinicians for possible BSIs. The timely initiation of empirical antibiotics and rapid de-escalation is vital to improve the outcome. At the same time, strict compliance of infection control practices should be accomplished to reduce the occurrence of MDRO.

Introduction – Liver abscess (especially amoebic) is an important health concern in tropical countries. Effective management of liver abscess included appropriate antibiotics and drainage of abscess cavity. Percutaneous abscess drainage by pigtail catherization is now gaining popularity. We analysed the role of pigtail catheter drainage in the treatment of liver abscess.Method and Material – This was a retrospective analytical study conducted in a tertiary care center in western India. Data of total 64 patients admitted with diagnosis of liver abscess were analyzed. To find the effectiveness of treatment data were analyzed in three groups based on treatment strategies, Group A (Conservative treatment), Group B (Percutaneous needle aspiration) and Group C (Pigtail catheter drainage).Results – A total of 64 patients of liver abscess were analyzed. There was male predominance (93.75%). Mean abscess volume in Group C (307.9 ± 212.8 ml) was significantly higher when compared to Group A (130.8 ± 72.9 ml, p = 0.03) and Group B (177.2 ± 129.5; p = 0.024). Duration of hospital stay and residual abscess volume at the time of discharge did not show statistically significant difference between treatment groups. Pigtail catheterization of abscess with volume >150ml shortened the hospital stay, whereas it prolonged the hospital stay in patients with abscess volume Conclusion - Percutaneous pigtail catherization would be an operative decision for management of liver abscess. We concluded that use of pigtail catherization of patients with abscess volume > 150ml improved the clinical outcome.

Background:: The understanding of pathogenesis is necessary for the development of effective treatment for COVID-19. Various studies have postulated that there is a complex interplay of mediators of coagulation and inflammation responsible for the pathogenesis of COVID-19. We did this study on coagulation parameters and inflammatory markers and their effect on outcome in patients with COVID-19. Methods: This was a single centre observational cross-sectional study. Procoagulants [Prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, lupus anticoagulant (LA), fibrinogen, factor-VIII (F-VIII)]; anticoagulants [protein-C (PC), protein-S (PS), antithrombin] and inflammatory markers [interleukin-6 (IL-6) and highly sensitive – C-reactive protein (hs-CRP)] were measured at the time of hospitalization and correlated with the severity of the disease. Results: A total of 230 patients were enrolled, of which 61.3%, 20.0%, and 18.7% had asymptomatic/ mild, moderate, or severe disease, respectively. COVID-19 disease severity was associated with rising trends with coagulation parameters (PT, APTT, D-Dimer; p value 0.01, Conclusions: This study revealed increased levels of coagulation and inflammatory parameters, which correlated with the severity of COVID-19. Age, D-dimer, IL-6, hs-CRP, APTT, fibrinogen, and Factor VIII were significantly higher in patients with moderate and severe disease as compared to asymptomatic/mild disease. Advanced age, high D-dimer, and high hs-CRP were significantly associated with poor outcomes.

Aspergillus is a ubiquitous ascomycete that can cause a variety of clinical presentations depending on immune status. Central nervous system aspergillosis is a fatal disease with non-specific clinical features. The aim of this systematic review was to evaluate the epidemiology, clinical features, diagnosis and therapeutic interventions in CNS aspergillosis patients. We also aimed to examine the possible predictors of mortality in neuroaspergillosis. Literature search was performed in Medline, PubMed, and Google scholar and all patients ≥ 18 years with proven CNS aspergillosis were included. A total of 175 articles (235 patients) were included in the final analysis. Their mean age was 51 years and the majority were male (57.4%). Overall case-fatality was 45.1%. Aspergillus fumigatus was the most common species (70.8%) followed by A. flavus (18.6%). Corticosteroids (22.6%), malignancy (19.1%) and diabetes mellitus (14%) were the most common risk factors. Neuroimaging findings included cerebral abscess (70.2%), meningitis (14%), infarction (13.2%) and mycotic aneurysm (8.9%). Disseminated disease (29.2% vs 17.8%, p 0.03), CSF hypoglycorrhachia (48.1% vs 22.2%, P: 0.001) and heightened CSF galactomannan (3.62 vs 2.0 ng/ml, p 0.05), were the factors associated with poor outcome in neuroaspergillosis. Persons infected with Aspergillus flavus (13.1% vs 3.1%, P: 0.01), and having been treated with Voriconazole (51.9% vs 29.2%, P: 0.004) were more likely to survive. Our review will provide insight into the different spectrums of CNS aspergillosis. Notwithstanding the promising role of Voriconazole, future work is required to ascertain the role of combination antifungal therapy.

Finding spurious thrombocytopenia is a common occurrence in clinical practice, whereas pseudothrombocytosis is a very uncommon event. Despite several technical advancements in automated haematology analysers, a careful peripheral smear examination remains standard examination in cases of discrepancy of platelet counts. We are presenting a case of betathalassaemia intermedia who had pseudothrombocytosis, which was falsely labelled as myeloproliferative neoplasm before the patient visited our haematology clinic.

Introduction The etiopathogenesis of purulent pericarditis has changed significantly in modern antibiotic era with the emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the last few decades. Pericarditis due to MRSA is rarely reported in the literature without risk factors like immunosuppression, thoracic surgery, chest trauma or pre-existing pericardial diseases. Case report We describe an 18-year-old male who presented with 5 days history of fever, chest pain and shortness of breath. Echocardiogram and thorax CT showed significant pericardial effusion. The patient underwent pericardiocentesis, MRSA was isolated from blood and pericardial fluid. The patient improved with intravenous antibiotics (linezolid). Follow-up echocardiography at 3 months was unremarkable, without any residual fluid or features of constrictive pericarditis. Discussion In the absence of known risk factors, MRSA is an extremely rare cause of pericarditis in modern antibiotics era. The possibility of MRSA pericarditis should be sought in every case of pericarditis to achieve prompt diagnosis and treatment. Conclusions Our case highlights the role of aggressive pericardiocentesis and appropriate antibiotic therapy in purulent pericarditis.

Introduction Evolution of targeted molecular therapies has greatly improved patient survival in cancer. Gefitinib is an oral, reversible, epidermal growth factor receptor inhibitor used in advance non-small cell lung cancer. Skin rashes and diarrhea are common adverse effects associated with gefitinib. However, electrolytes disorders are rarely reported with gefitinib, particularly hyponatremia. Case report We describe a 65-year-old male with metastatic non-small cell lung cancer treated with gefitinib for the last three weeks. He presented to our hospital with complaints of acute onset drowsiness. On evaluation of drowsiness, patient was diagnosed with severe hyponatremia. Management and outcome: After ruling out other common causes of hyponatremia, gefitinib was attributed as a cause of hyponatremia. Gefitinib was immediately stopped and IV hypertonic saline (3% sodium chloride) was started due to severe symptomatic hyponatremia. After seven days of cessation of gefitinib, he became asymptomatic with normalisation of serum sodium levels. Discussion Hyponatremia in cancer patients is associated with poor prognosis and prolonged hospital stay. Possibility of gefitinib-induced hyponatremia should be considered in order to achieve early diagnosis and prevent significant mortality in cancer patients.

Highlights • Pulmonary Nocardiosis is a rare bacterial disease which predominantly affects the immunocompromised patients. • The coexistence of Pulmonary Nocardiosis and Aspergillosis is rarely reported in the literature. • Pulmonary Nocardiosis and Aspergillosis can occur concomitantly in an immunocompetent patient with COPD or other structural lung diseases alone as a risk factor., Pulmonary Nocardiosis and invasive Aspergillosis are well documented in immunocompromised patients. The coexistence of both infections is a diagnostic rarity, especially in patients with underlying structural lung diseases. We describe this rare association in a 46-year-old female with a history of pulmonary tuberculosis and COPD. The diagnosis of pulmonary Nocardiosis is challenging due to non-specific clinical features, inherent ability to mimic malignancy, tuberculosis and difficulty in the cultivation of the organism. The treating physicians should aware of the rare occurrence of such co-infections in order to prevent misdiagnosis and prompt treatment.

We report the case of an 84-year-old female presented to us with acute onset altered sensorium. On investigation, neurological and infectious causes were ruled out. On further evaluation, her serum calcium was found elevated (15.07 gm/dl). The diagnosis of hypercalcemic encephalopathy was made with the possibility of multiple myeloma due to raised total protein and globulin levels. Serum electrophoresis, immunofixation, and bone marrow examination confirmed the diagnosis of multiple myeloma. The patient was treated with bortezomib, dexamethasone, and lenalidomide. After 1 week, she improved with normalization of serum calcium. Herein, we highlight hypercalcemia as an important cause of encephalopathy. As our report suggests, metabolic encephalopathy can be the first presentation in multiple myeloma.

Background Cryptococcal meningitis is a dreaded complication in HIV infected patients. It was associated with high mortality and morbidity before the advent of Highly Active Anti-Retroviral Therapy. A study was planned in our institute to evaluate the clinical profile, laboratory findings, and prognostic factors for survival in these patients. Settings and design A prospective hospital-based observational study, conducted in the Department of Medicine at a tertiary care centre in western Rajasthan. Method and material HIV infected patients presenting with clinical features of meningitis, and positive CSF culture for Cryptococcus were included in our study. All cases underwent detailed clinical history, physical examinations and relevant laboratory investigations including CD4 count and CSF examination. Results 48 HIV infected cryptococcal meningitis patients were analysed, and the most common presenting clinical features were headache (85.42%), and fever (72.92%), followed by neck stiffness (62.50%). CSF examination was also done for Cryptococcal Antigen test which was reactive in all cases (100%), and India ink staining was positive in 43 cases (89.58%). Significant fatal outcome was associated with patients presenting with altered sensorium, loss of consciousness, cranial nerve palsy and CD4 cell count of less than 100. Similarly, on laboratory and imaging diagnosis, cryptococcal antigen test (>3+reactive), fundus examination (papilloedema) and abnormal CT/MRI brain imaging were associated with poor survival. Conclusion Cryptococcal meningitis is a potentially lethal infection in immunocompromised individuals and should be diagnosed early with high clinical suspicion as around 10% of the cases may not be detected on India ink staining and a large proportion (75%) of cases may have normal imaging at initial evaluation. Early diagnosis, watchful eye on prognostic factors and treatment is vital to improve outcome in these patients.

Sjogren’s syndrome (SS) is a chronic systemic autoimmune disease, characterized by lymphocytic infiltration of lacrimal and salivary glands. Although extra glandular manifestations are uncommon, they can occur with the musculoskeletal, renal, pulmonary and hematological disease. We report the case of a 35-year-old woman presented to us with persistent unexplained bicytopenia (anemia and thrombocytopenia). Antinuclear antibody and direct Coombs test were positive. Anti-Ro/SSA and anti-La/SSB antibodies were also positive in high titer. The final diagnosis of primary SS with autoimmune cytopenia was made. Cytopenias in SS are rarely reported. Our case illustrates that clinically significant cytopenias may present as an extraglandular manifestation of SS.

Moyamoya disease is a chronic progressive cerebrovascular disease characterized by bilateral occlusion or stenosis of arteries around circle of Willis. We report a case of 18-year-old female presented with recurrent episodes of headache and vertigo. On cerebral angiography, the patient was diagnosed to have moyamoya disease. On further evaluation, thrombophilia profile showed increased homocysteine level. The patient was treated conservatively with cobalamin and aspirin and advised for revascularization. According to the literature, there are few case reports of moyamoya disease with thrombotic disorders. Hence, we are reporting this interesting and rare case.

We report a case of 56-year-old man presented to us with chief complaints of frothy urine and leg swelling. A urinalysis revealed nephrotic-range proteinuria. Haematological investigations revealed thrombocytosis, leucocytosis and peripheral blood smear showed a leucoerythroblastic picture. JAK 2 mutation was positive. To confirm the diagnosis of myeloproliferative neoplasm, bone marrow biopsy was done, which was suggestive of primary myelofibrosis. The patient underwent kidney biopsy due to rapidly declining renal function and persistent proteinuria, which was suggestive of focal segmental glomerulosclerosis. Early glomerulopathy is rare in myeloproliferative neoplasm, and aggressive follow-up is required to prevent progression of kidney disease.

We report a case of 26-year-old man who was admitted on our ward for the evaluation of ascites. He was a known case of inflammatory bowel disease(ulcerative colitis) and was on regular mesalamine therapy. On evaluation, he was having high serum ascites albumin gradient. CT scan of the abdomen revealed features of portal hypertension and non-visualisation of right and middle hepatic veins along with thrombus in inferior vena cava, suggesting a diagnosis of Budd-Chiari syndrome (BCS). There are only few case reports available showing association of BCS with UC. Hence, we are reporting this interesting and rare case.