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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%.

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.

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.

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.

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.

Background: Scrub typhus has emerged as a major cause of acute febrile illness in India in recent years. The causative agent, Orientia tsutsugamushi has more than 20 prototype strains due to a variable 56-kDa outer membrane protein. It is crucial to know the prevailing types in India for the success of diagnostic immunoassays and prospective vaccine candidates. In north India, the principal types circulating are largely unknown. Our tertiary care hospital caters to a large area of north India (around 7 states and one union territory). Therefore, the current study was planned to identify the genotypes of O. tsutsugamushi strains circulating in this wide area of north India. Materials and methods: Adults and children presenting with suspected scrub typhus between July 2013 and December 2013 were included in this study. DNA was extracted from whole blood and a nested PCR was used to amplify a 483-bp region of the 56-kDa antigen gene of O. tsutsugamushi. The PCR products were purified and DNA sequencing was performed and aligned using the CLUSTAL_X2 program. A phylogenetic tree was constructed using neighbour- joining algorithms and analysed using the sequences obtained in this study and those obtained from the GenBank database. Results: A total of 34 samples were positive for PCR. The amplicons were sequenced and analyzed. Karp-like strains predominated in all states studied (64.7%) followed by Gilliam-like (26.47 %) and 8.82% similar to Hualien 1 or S072. We did not find any Kato or Kawasaki-like strain. Karp like strains showed >99% similarity to TH2033, TH2191, TH2208, Xinjiang & Neimeng strains and Gilliam-like strains showed >99% similarity to Clone ISS -11. Conclusion: Orientia tsutsugamushi shows a great diversity in its strains over a large geographical area of north India. This has implications in the production of both diagnostic assays and vaccine for scrub typhus. Keywords: Scrub typhus, Orientia tsutsugamushi, Eschar, North India

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.

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 …

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.

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)

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.

Histoplasmosis is usually clinically suspected only in people who reside in, are migrants from or are travelling to endemic areas such as North America. Immunocompetent patients with a low level of exposure typically have either subclinical or mild and self-limiting infection. The most common risk for the development of progressive disseminated form is HIV infection. We recently managed two patients with disseminated histoplasmosis, presenting with prolonged fever, significant weight loss, pallor and hepatosplenomegaly. Both were HIV-negative and lived in Himachal Pradesh (India), a region that was considered “ Histoplasma-free” until recently.

Background: Tremendous infectious disease burden and rapid emergence of multidrug resistant pathogens continues to burden our healthcare system. Antibiotic stewardship program often implements antibiotic policies that help in preventing unnecessary use of antibiotics and in optimizing management. To develop such a policy for management of infections in the emergency unit, it is important to analyze the information regarding antibiotic prescription patterns in patients presenting to the emergency room referred from various healthcare settings. This study was conducted with the aforementioned background. Methods: We conducted a prospective observational study in triage area of emergency unit of a tertiary care hospital. All the referred patients were screened for antibiotic prescription. Data extraction form was used to capture information on patient demographics, diagnosis and antibiotics prescribed. Antibiotic prescription details with regard to dosage, duration and frequency of antimicrobial administration were also recorded. Data were summarized using descriptive statistics as appropriate. Results: Out of 517 screened patients, 300 were prescribed antimicrobials. Out of 29 antibiotics prescribed, 12 were prescribed in more than 90% of patients. Broad spectrum antibiotics accounted for 67.3% of prescriptions. In 129 out of 300 patients, no evidence of infectious etiology was found. Conclusion: Our study highlights some common but serious lapses in antibiotic prescription patterns in patients referred from various healthcare settings. This emphasizes the need to provide training for rational use of antibiotics across healthcare settings.

Scrub typhus caused by Orientia tsutsugamushi presents as an acute febrile illness with a varied presentation from mild illness to fatal disease in the absence of appropriate antibiotic treatment. Performing polymerase chain reaction (PCR) on eschar sample acts a rapid diagnostic tool in the early stage of scrub typhus when blood is negative. A total of eight patients from whom both whole blood and eschar samples were collected and tested by nested PCR targeting 56 kDa trichostatin A (TSA) gene to detect O. tsutsugamushi DNA. All (100%) eschar samples and three whole blood samples tested positive. Genetic analysis of the 56 kDa TSA gene sequences showed that the majority were related to Karp reference strains, while one clustered with Kawasaki strain. When present, eschar should be favoured as a diagnostic sample over whole blood in the early phase of infection.

Background As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. Aims The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. Methods The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. Results A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Conclusions Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

There is paucity of data on infusion related hypersensitivity reactions (IRHR) pattern of bio-similar rituximab in B-cell lymphoma patients. As bio-similar molecules are independently developed monoclonal antibodies, they are likely to differ in immunogenicity and therefore, the hypersensitivity data of the innovator rituximab may not be directly applicable to patients treated with the biosimilar rituximab molecule. We analysed our data of 256 patients of B cell lymphoid neoplasm who received bio-similar rituximab (Reditux) based chemo-immunotherapy for their treatment. Total 56/256 (21.8%) patients had ≥ grade II IRHR with first dose of rituximab. Grade II reactions were seen in 32/256 (12.5%) cases, grade III and grade IV reactions were seen in 21/256 (8.2%) and 3/256 (1.2%) cases, respectively. Rituximab was withdrawn from all further therapy in only 2 patients due to grade IV IRHR after attempting re-challenge of the drug under intensive monitoring. There was no difference in complete response rates in patients with or without IRHR during their first rituximab infusion. The IRHRs with bio-similar rituximab noted in our study were comparable with the previously published reactions associated with the original rituximab.

Purpose The introduction of tyrosine kinase inhibitors has transformed the care of patients with chronic myeloid leukemia, with survival approaching that of healthy individuals. Current-day challenges in chronic myeloid leukemia care include adherence to tyrosine kinase inhibitor therapy. We studied adherence from resource-constrained settings and tried to analyze the factors responsible for nonadherence in these individuals. We also correlated adherence to current molecular status. Patients and Methods This was a single-center, cross-sectional, observational study from north India. It consisted of a questionnaire-based survey in which a one-to-one interview technique was used by trained nursing staff administering the Modified Morisky Adherence Scale (MMAS-9) questionnaire. Adherence was also measured on the basis of physician’s assessment. JMP 13.0.0 was used for statistical analysis. Results A total of 333 patients with a median age of 42 years were included in the study. The median BCR-ABL/ABL ratio (IS) was 0.175 (0.0 to 98.0). The mean MMAS-9 score was 11 ± 2. Adherence was seen in 54.95% on the basis of MMAS-9, whereas physician’s assessment reported adherence in 90.39% of patients. Using the χ2 test, no relationship was found between the two assessment techniques. There was a significant relationship between major molecular response status and adherence by physician’s assessment and MMAS-9 ( P < .001). Bivariate analysis by logistic fit showed a good relation between the MMAS-9 score and the BCR-ABL/ABL ratio (IS), χ2 (1,220) = 135.45 ( P < .001). On multivariate analysis, enrolment in the Novartis Oncology Access program (a patient assistance program) was significantly associated with adherence ( P = .012). Conclusion This study highlights the lack of adherence in real-world settings and the various factors responsible. Such studies are important from a public health services perspective in various settings around the world because they may lead to corrective action being taken at the institutional level.

Objective: To evaluate the efficacy of a single intravenous (IV) dose of anti-D in severe thrombocytopenia ( Materials and Methods: An open label, investigator-initiated, randomized interventional study was conducted that included thirty dengue patients (all positive for IgM enzyme-linked immunosorbent assay) with severe thrombocytopenia ( 3 ). Patients were randomized to receive anti-D (50 μg/kg single IV dose) plus supportive therapy or supportive therapy alone. Results: The rate of rise in platelet count was significantly high in the intervention group at 24, 36, and 48 h. At the end of 48 h, 60% patients in the intervention group achieved a platelet count of ≥50,000/mm 3 as compared to 6.7% in the control group ( P = 0.0019). The requirement of the platelet concentrate infusion in the control group was significantly higher, i.e. 342 ml (±193) as compared to the intervention group requiring only 187 ml (±79). The intervention group showed a significant improvement in bleeding manifestations in all the patients by 24 h in Grade 2 bleed ( P = 0.032) and by 48 h in Grade 1 bleed ( P = 0.014). Conclusions: Severe thrombocytopenia (≤20,000/mm 3 ) secondary to DEV infection was rapidly and safely reversed by administration of a single dose of 50 μg/kg (250 IU/kg) anti-D IV.

Dengue is a common arthropod-borne flavivirus and commonly manifests as fever, bleeding diathesis, and capillary leak syndrome. Neurological manifestations are uncommon except for encephalopathy. We have recently had the opportunity of observing two patients with rare neurological complications of dengue, transverse myelitis, and Guillain-Barré syndrome. Both the cases had good neurological recovery with steroid and intravenous immunoglobulin, respectively. How to cite this article: Singh H, Pannu AK, Bhalla A, Suri V, Kumari S. Dengue: Uncommon Neurological Presentations of a Common Tropical Illness. Indian J Crit Care Med 2019;23(6):274–275.

Background To date, no study has evaluated the association of alcohol dependence with the outcome of the COVID-19 infection. Aim The current study aimed to evaluate the association of substance dependence (alcohol and tobacco) with the outcome (i.e., time to have two consecutive negative test reports) of the COVID-19 infection. Results The mean age of the study participants (n = 95) was 37.2 yrs (SD-13.2). More than half of the participants were males. About one-fourth (N = 25; 26.3 %) were consuming various substances in a dependent pattern. Alcohol dependence was present in 21 participants (22.1 %), and Tobacco dependence was present in 10.5 % of participants. Even after using gender, age, and physical illness as covariates, patients with any kind of substance dependence had a significantly lower chance of having a negative report on RT-PCR on 14th day, 18th 23rd day. Conclusion Persons with substance dependence takes a longer time to test negative on RT-PCR, once diagnosed with COVID-19 infection. Mental health professionals involved in the care of patients with COVID-19 should accordingly prepare these patients for a possible longer hospital stay to reduce the distress associated with prolongation of hospital stay.

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR–positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19–positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of

Background & objectives: The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India. Methods: Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines. Results: During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO224). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed. Interpretation & conclusions: Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality.

Aim The aim of this study was to evaluate the prevalence of mild cognitive impairment (MCI) in patients with hypertension and to evaluate the association of MCI with metabolic syndrome (MetS). Methodology 186 subjects with hypertension were evaluated on Montreal Cognitive Assessment (MoCA) and Patient Health Questionnaire (PHQ-9) for cognitive decline and depression, respectively and MetS was diagnosed as per the Consensus definition. Results The prevalence of MCI was 65.6 % and that of MetS was 45.7 %. Compared to those without MetS, those with MetS had significantly poorer cognitive functioning on the all cognitive domain of the MoCA, even after controlling for age, education, severity of the depression and duration of illness. Low High-Density Lipoprotein (HDL) was found to have a positive correlation with MoCA. Higher age, lower education, higher duration of illness and use of higher numbers of medications were associated with significantly lower score on MoCA. Conclusion Presence of MetS among persons with hypertension is associated with cognitive decline. Hence, there is a need to monitor and manage other parameters of MetS among patients with hypertension, to reduce the risk of cognitive decline and future dementia.

Background & objectives: In India, spotted fever group rickettsiae (SFGR) are an underdiagnosed cause of acute febrile illness (AFI). The non-specific Weil-Felix test is the first diagnostic modality for the diagnosis of SFGR in many laboratories due to the lack of advanced diagnostic facilities in developing countries. The aim of this study was to detect SFGR using molecular methods in the patients, presenting with AFI in a tertiary care centre in north India. Methods: Consecutive patients (>14 yr of age) with AFI were enrolled over a six month period. Standard investigations for common pathogens causing AFI in India (malaria, dengue, scrub typhus, leptospirosis and enteric fever) were carried out. In patients who were negative for all of the above investigations, blood was subjected to polymerase chain reaction (PCR) targeting outer membrane protein A (ompA) gene of Rickettsia. Results: Of the 51 patients with an undiagnosed aetiology, three were positive by ompA PCR. Two of the PCR products produced good sequences and BLAST identification confirmed them as Rickettsia conorii. The sequences of R. conorii reported from south India clustered with two previously reported novel rickettsial genotypes. The study sequences clustered in a group different from that of Rickettsia spp. of the south Indian sequences reported earlier. Interpretation & conclusions: This study showed the existence of R. conorii in north India. Testing for SFGR may be included in the diagnostic workup of AFI for better disease management.

Introduction Deep vein thrombosis is a multifactorial disease with many acquired and genetic risk factors. Polymorphism in the APOE gene is an upcoming potential pathogenic factor whose role is unclear in deep vein thrombosis. Methods An equal number of deep vein thrombosis cases and controls (N = 100, each) were investigated for APOE gene polymorphisms along with known acquired and hereditable thrombophilic risk factors. APOE genotyping was done by polymerase chain reaction. Results The ε3/ε4 and ε2/ε3 APOE genotypes were commoner in deep vein thrombosis cases than controls but not statistically significant ( ε3/ε4 → 18% versus 11%, OR = 1.776, CI = 0.792–3.984, p = 0.16; ε2/ε3 →10% versus 9%, OR = 1.123, CI = 0.436–2.895, p = 0.809). However, the following risk factors were found to be laterally associated with APOE genotypes in cases of deep vein thrombosis: pregnancy with ε2/ε3 genotype positivity (N = 29; p = 0.019), recurrent pregnancy loss with ε3/ε3 genotype (N = 29; p = 0.016), normal antithrombin levels with ε3/ε3 genotype (N = 62; p = 0.03) and non-O blood group with ε3/ε4 genotype (N = 100; p = 0.023). Conclusion APOE genotypes have shown only a modest association with deep vein thrombosis and were not statistically significant. A lateral association of these genotypes with thrombophilic risk factors was observed which may be investigated further for the possible pathogenetic mechanisms and their therapeutic implications.

Background To study the clinical profile and outcome of adult patients presenting with Scrub typhus ARDS in emergency at our institute. Methods Prospective observational study which included 126 adult patients presenting to emergency department at, PGIMER Chandigarh, a tertiary care referral institute in northwestern India with acute febrile illness with ARDS (acute onset respiratory distress within one week of fever or new/worsening respiratory symptoms with PaO2/FiO2 ratio less than 300 with PEEP or CPAP more than 5 cm H2O from January 2016 to December 2017.All the patients consenting for the study underwent detailed clinical evaluation and investigated for the etiology as per standard protocol followed at our institute with special emphasis to rule out tropical illnesses like scrub typhus, malaria, leptospirosis, dengue and H1N1 influenza. Patients were followed till discharge. Results Out of 126 patients eligible for the study, 45.2% were males and 54.8% were females. 47.6% were admitted in the monsoon/post-monsoon period. In addition to fever and dyspnea, cough (75.8%), hepatomegaly (56%), myalgia (63%), splenomegaly (31.3%), pedal edema (34.2%), pallor (40.4%), and vomiting (48.4%) were the common symptoms observed. Scrub typhus in 33.3%, followed by H1N1 influenza in 15.8%, co-infections in 12.6%, leptospirosis in (4.76%), dengue in (3.96%) and malaria in 3.17% of the patients, were the most common etiologies encountered. In 26.9% patients, no definite infective etiology could be found. Among the scrub typhus patients, 16 required ventilation. SOFA score of more than 6 was noted in 24 (57.14%) patients with scrub typhus as compared 9 (47.3%) patients with H1N1 infection. 12.1% of patients with scrub typhus succumbed to their illness when compared with 36.8% of patients with H1N1 infection. At admission in emergency female sex (P = 0.048), age less than 45 years, (P = 0.020), abdominal pain (P = 0.011), presence of hepatosplenomegaly (P = 0.001/0.010), thrombocytopenia Conclusion Scrub typhus is an important, treatable tropical infection causing ARDS especially in monsoon/post-monsoon seasons in Northwestern India. Disclosures All authors: No reported disclosures.

There is controversy about whether 3- or 6-month molecular assessment predicts progression-free and overall survival in those with chronic myeloid leukemia (CML). The factors predicting molecular response at 3, 6, and 12 months have not been studied extensively. The study objective was to study the factors affecting molecular response at 3 and 6 months in patients with CML who are receiving imatinib mesylate.We prospectively enrolled patients with newly diagnosed CML who were receiving imatinib mesylate as the initial therapy for CML. The diagnosis of CML was based on clinical examination, bone marrow, and demonstration of BCR ABL(IS) transcripts by polymerase chain reaction. The molecular response(IS) was assessed at 3, 6, and 12 months by GeneXpert (Cepheid, Sunnyvale, CA) and co-related with various baseline characteristics of patients. We also looked at whether early achievement of a complete hematologic response within 6 weeks predicts molecular response at 3 or 6 months. The study took place at a tertiary care hospital in Northwest India catering to patients belonging to low-middle socioeconomic status.We enrolled 131 patients with CML in the chronic phase from July 1, 2013, to August 31, 2014. The median age of the patients was 40 years (range, 13-67) with a male preponderance (61% were male). Most patients presented with symptoms of low-grade fever (52.7%) and abdominal fullness (26.7%). Spleen was palpable in 84.7% of patients. The median hemoglobin at presentation was 10.8 g/dL (range, 4.8-18.4 g/dL), white cell count was 138.3 × 10(9)/L (4.1-697 × 10(9)/L), and platelet count was 326 × 10(9)/L (85-1819 × 10(9)/L). The median number of peripheral blood basophils was 3% (range, 0%-20%), and blasts were 3% (range, 0%-10%). Myelofibrosis of more than grade 1 was present in 30% of patients. Most patients belonged to intermediate Sokal (45.8%) and Hasford (55%) scores and low EUropean Treatment Outcome Study (78.6%) score. Of 128 evaluable patients at 3 months, 96.9% achieved complete hematologic remission (CHR) and 82.3% achieved BCR ABL(IS) of less than 10%. None of the patients who had BCR ABL(IS)10% at 3 months achieved BCR ABL(IS)1% at 6 months or0.1% at 12 months. Early achievement of CHR (6 weeks), peripheral blood blast count of5%, and lactate dehydrogenase851 U/L were significantly associated with achievement of BCR ABL(IS)10% at 3 months and BCR ABL(IS)1% at 6 months.We found that BCR ABL(IS) assessment at 3 months is superior to assessment at 6 months. Patients with CML in the chronic phase who achieve CHR within 6 weeks are more likely to achieve BCR ABL(IS)10% at 3 months and1% at 6 months than patients who achieve CHR between 7 and 12 weeks.