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Umbilical cord milking (UCM) has been theorized to increase placental blood transfusion then again, the optimal method of cord clamping at birth is still contested. We aimed to analyse the effects of UCM on the neonatal haematological parameters at 72 h and 6 weeks of age and its association with any adverse effects. In this randomized control trial, mothers ≥ 34 weeks were randomized into two arms. Under the intervention group, the cord was milked three times before clamping and cutting whereas the controls had the cord clamped and cut without milking. Haemoglobin and haematocrit levels were measured at 72 h. and at 6 weeks. A total of 170 mothers were enrolled with 85 subjects in each arm. Baseline characteristics were comparable. In the intervention arm, the mean haemoglobin [18.1 (2.4) g/dL] and haematocrit [54 (7) %] were significantly higher as compared to the control arm [16.4 (2.1) g/dL and 48 (6) %], at 72 h of age. There was also significant increase in the mean haemoglobin [11.6 (1.3) g/dL] and haematocrit [34 (4) %] compared to the controls [10.1 (1.1) g/dL and 30 (3) %], at 6 weeks. No statistical difference was found in the incidence of PPH and duration of third stage. There was no significant rise in hyperbilirubinaemia, phototherapy requirement and polycythaemia among neonates in the intervention group. Umbilical cord milking is a sound practical approach to raise the haemoglobin and haematocrit levels up to 6 weeks thereby decreasing the proportion of anaemic infants.

Ajay Kumar Mishra,1 Harshad Arvind Vanjare,2 Anu Anna George,1 Kamal Kant Sahu1 1Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA; 2Department of Radiology, Christian Medical College, Vellore, IndiaCorrespondence: Kamal Kant SahuDepartment of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, USAEmail drkksahu85@gmail.comAbstract: Individuals presenting with sudden and focal neurological findings are usually suspected to have stroke. However, there are other conditions that can simulate stroke, which are often referred to as stroke mimics. Awareness and understanding these stroke-like disorders are of extreme importance as the treatment of each of them might be variable. We hereby briefly discuss these stroke mimics, common differentials, and key features to differentiate amongst the various causes of acute neurological event. Stroke is one of the neurological emergencies that needs urgent intervention to prevent significant mortality and morbidity. At the same time, it is important to realize the importance of other conditions which may mimic to stroke. In this letter, we aim to discuss a few key features that could probably help to distinguish stroke from mimickers thereby helping emergency doctors, neurologists, and hospitalists in streamlining the correct treatment at the earliest.Keywords: COVID-19, stroke, virus, SARS-CoV-2, neurology

Background: In the setting of the current pandemic, concerns have arisen regarding the multisystemic involvement of sarcoidosis and the possible exacerbations in response to the exposure to severe acute respiratory syndrome coronavirus 2. Aim: This study aims to compare the differences in clinical presentation, management, and outcome of coronavirus disease 2019 (COVID-19) between patients with sarcoidosis and those in the general population. Methods: A literature search was conducted by reviewing original research articles such as case reports, case series, observational studies, and questionnaire-based surveys published in PubMed/Medline, Web of Science, and Google scholar. Data from individual patients in case series and case reports have been pooled to create a data set that was compared with larger such cohorts obtained from several other observational studies. Results: Twenty-seven patients were identified from 14 original articles. No significant differences were found in the clinical manifestations of patients with sarcoidosis presenting with COVID-19 as compared to the general population. The rate of hospitalization in our study was found to be 48.1%. The overall mortality in our study was 7.4%, which is higher than the global average of 2.1%. Conclusion: Our observations have reinforced the hypothesis that the presence of additional medical comorbidities is associated with a higher risk of intensive care unit admission. Furthermore, the presence of moderate to a severe limitation in pulmonary functions is an additional risk factor associated with increased hospital admissions and mortality in sarcoidosis. However, neither the diagnosis of sarcoidosis nor ongoing treatment with steroids, methotrexate, or other immunosuppressants was associated with a poorer prognosis in patients with sarcoidosis. Relevance for patients: Patients with sarcoidosis must take added precautions to mitigate the risk of acquiring COVID-19 infection in view of the COVID-19-related mortality rate in this group of patients. Specifically, immunocompromised patients (on immunomodulator drugs and high dose steroids) have been found to have an increased risk of contracting COVID-19. Overall impact on prognostication and outcome in cases requiring hospitalization remains yet to be determined.

Dear Editor, We read with much excitement in the article “Takotsubo syndrome and pheochromocytoma: an insidious combination” published by Maffé et al. in your esteemed journal...

Coronavirus disease (COVID 19) has involved millions of people all over the world. Tuberculosis (TB) continues to affect millions of people every year with high mortality. There is limited literature on the occurrence of COVID 19 in patients with TB. We reviewed the available data on various clinical details, management, and outcome among patients with COVID-19 and TB. 8 studies reported a total of 80 patients with this coinfection. These patients were reported from 9 different countries, with Italy reporting the largest number of cases. Migrant, males constituted a major proportion of cases. Most reported patients were symptomatic. Fever, dry cough, and dyspnea were the most commonly reported symptoms. Bilateral ground glass opacities were more common in COVID 19 infection and cavitary lesions were more common in patients with TB. Most reported TB patients had been found to have mycobacterium tuberculosis from sputum culture in the background of pulmonary TB. Most patients of TB were treated with multidrug regimen antitubercular therapy. In all 8 studies, COVID 19 was treated as per the local protocol. Mortality was reported in more than 10% of patients. Mortality was higher in elderly patients (> 70 years) and amongst patient with multiple medical comorbidities. (www.actabiomedica.it)

Highlights • Acute cardiac injury is the most common cardiac manifestation in patients with COVID -19 and can be seen in patients without prior cardiac comorbidities. • Prior cardiovascular risk factors predispose to cardiac injury, severity of illness and mortality. • Cardiac markers are instrumental in the diagnosis of cardiac injury. An elevated cTnI is both diagnostic and prognostic in these patients. • Electrocardiographic, echocardiographic and cardiac imaging details are limited. • Multiple mechanisms and processes contribute to cardiac injury resulting in a poor outcome. • Non-ischemic myocardial injury secondary to cytokine storm is thought to be the predominant mechanism of acute cardiac injury. • Multiple risk factors have been thought to predispose to cardiac injury, the severity of illness in patients with cardiac injury, and mortality., Coronavirus disease (COVID-19) pandemic has so far involved 184 countries and more than 2.79 million patients worldwide. Over the past three months, it has attributed to more than 196, 000 deaths, with more than 50, 000 deaths in the United States alone. Pulmonary manifestations are predominant and have been well identified. Cardiac involvement is also common. Acute cardiac injury, the most common cardiac manifestation of this disease can be seen in patients even without prior cardiac comorbidities. Established cardiovascular risk factors such as diabetes mellitus, hypertension, and coronary artery disease predispose to cardiac injury, the severity of illness and mortality. Non-ischemic myocardial injury secondary to cytokine storm is thought to be the predominant mechanism of acute cardiac injury associated with COVID-19. Multiple mechanisms and processes contribute to cardiac injury resulting in a poor outcome. Some of these are not clearly understood. Clinical and diagnostic details of cardiovascular involvement in these patients are mostly limited to biochemical markers. Multiple therapeutic agents have been tried with questionable efficacy and without clinical evidence. Interactions of comorbidities, cardiovascular drugs, the cardiac effect of therapeutic agents on the illness continue to be under investigation. With an increasing number of patients, newer promising therapies, and ongoing clinical trials, the exact mechanisms and extent to which these risk factors contribute to outcomes will be clearer in the future.

Background & objectives: Dengue fever (DF) is a common cause of acute febrile illness. Skin involvement is seen in more than half of the patients. This study was aimed to compare the clinical profile and outcome in DF patients with or without skin involvement. Methods: This study included all the patients with DF from the acute febrile illness database of a tertiary care health centre in south India. These patients were further subgrouped into SP and SN (skin involvement positive and negative) based on the presence and absence of skin rash. Differences in clinical presentation, laboratory parameters, disease course, morbidity and outcome among patients with DF with or without skin rash were recorded and analysed statistically. Results: In total 387 patients (>16 yr) with DF were enrolled into the study. Among these 55 patients had evidence of skin rash. Presence of history of overt bleeding (OR = 4.96, p = 0.027) including gum bleeding (OR = 1.17, p = 0.23), epistaxis (OR = 5.52, p = 0.04), and haematuria (OR = 6.41, p = 0.01) were more among patients with SP as compared to SN. The SP patients were found to have lower levels of platelets during the disease course. Patients with SP had a higher percentage of platelet transfusion which was statistically significant. There was no difference in organ dysfunction and mortality among both the groups. Interpretation & conclusion: Cutaneous involvement, though common, is not pathognomonic and can help in dengue diagnosis. Adult patients with skin rash can develop worsening thrombocytopenia requiring platelet transfusion. However, there are limited data to suggest that such patients have a worse outcome and higher mortality.

Background: Inflammation involving the postcapillary venular wall is defined as small vessel vasculitis. Small vessel vasculitis has various clinical manifestations. Etiologically, it can be primary or secondary. Literature regarding secondary vasculitis in elderly is scanty. Aim and Objectives: In this case series, we aimed to assess the clinical features and etiologies of biopsy-proven secondary small vessel vasculitis in the elderly. Methodology: Twelve elderly patients with biopsy-proven small vessel vasculitis were included in this study. All patients were thoroughly evaluated to assess the etiology and presence of major organ involvement. Results: Secondary small vessel vasculitis involved both the sexes equally. Constitutional symptoms including fever and weight loss were noticed by most of the (70%) patients. Neurological deficits were present in 83% of the study population. The most common finding in an electromyographic examination was an asymmetric sensory motor distal predominant polyradiculopathy. Fifty percent of the patients did fulfill the criteria for a definite autoimmune disease. More than 30% of the vasculitis was secondary to malignancies. Conclusions: Neurological manifestations are the most common systemic involvement in elderly patients with secondary vasculitis. Meticulous search for underlying malignancies is mandatory in elderly patients with secondary small vessel vasculitis.

Background: Ross syndrome is diagnosed by the presence of segmental anhidrosis, areflexia, and tonic pupils. Fewer than 60 cases have been described in literature so far. There have been reports of presence of antibodies in such patients, suggesting an autoimmune pathogenesis. Methods: We describe the clinical profile in this case series of 11 patients with Ross syndrome and discuss the current status of autoimmunity in its pathogenesis and the management. Results: Of the 11 patients with Ross syndrome there was an almost equal sex distribution (male:female ratio was 1.17:1) and the mean age of onset of symptoms was 26 years. Patients took an average of 6 years to present to a tertiary center. Sixty-three percent of the patients presented with complaints of excessive sweating, whereas only 27% had complaints of decreased sweating over a particular area of the body. Only 45% of the patients had the complete triad of Ross syndrome, which included segmental anhidrosis, tonic pupil, and absent reflexes. Eighty-nine percent of the patients had documented absent sympathetic skin response on electromyography. The various markers of autoimmunity were negative in all patients who were investigated for the same in this series. Ninety percent of the patients were managed conservatively. Conclusions: These findings suggest that, in Ross syndrome, generalized injury to ganglion cells or their projections are not purely autoimmune-mediated.

Yellow nail syndrome (YNS) is a rare entity characterized by a triad of nail changes, lymphoedema and lung involvement. We report a 57-year-old man with rheumatoid arthritis (RA) and YNS. We have reviewed the previous case reports of RA and YNS and discuss the pulmonary manifestations.

Background Dapsone treatment may reduce HbA1c levels in patients with diabetes. Aims To assess the prevalence and characteristics of dapsone associated reduction of HbA1c in patients with Hansen’s disease. Methods A retrospective data review of outpatient and inpatient charts of consecutive patients with Hansen’s disease and type 2 diabetes mellitus was conducted over two years from January 2014 to January 2016 at the Department of Dermatology, CMC Vellore, India. Results Of the 245 patients with a confirmed diagnosis of Hansen’s disease who were on oral dapsone 100 mg/day as part of their treatment regimen, 49 patients had diabetes and were eligible for the study as per predetermined inclusion criteria. Of these, 35 subjects (71%) had an HbA1c discordantly lower than the corresponding mean plasma glucose levels. Patients with discordant HbA1c levels were more likely to be male and to have a higher RBC mean corpuscular volume (MCV). A greater reduction in HbA1c levels was seen during the initial 3 months of therapy of dapsone treatment. Limitations The small sample size and retrospective design were limitations of this study. Also, we did not analyze the role of methemoglobinemia or the utility of alternative measures of glycemic control in these patients. Conclusion We describe a high prevalence of dapsone associated inappropriate HbA1c lowering in type 2 diabetes mellitus patients. This may have serious implications for the management of diabetes in patients on therapy with dapsone.

Cutaneous metastasis from visceral tumors is a rare entity with a reported incidence between 0.3% and 9.8%. These usually occur late in the course of the disease; the average time interval between the diagnosis of malignancy and presentation of cutaneous metastases has been reported to be 33 months. In rare instances (in about 0.8%–1.3% of patients), cutaneous metastases may be a pointer to an underlying undiagnosed malignancy. We report two patients presenting to us with soft, nodular, cutaneous lesions, which was the manifestation of metastatic signet cell carcinoma arising from the gut. We report these cases owing to their rarity.

Background Cryptococcal meningitis continues to be one of the common causes of chronic central nervous system infection worldwide. Individuals with cryptococcal meningitis can occasionally present with small vessel vasculitis causing infarcts primarily in the basal ganglia, internal capsule, and thalamus. Literature regarding patterns of cerebrovascular injury among patients with cryptococcal meningitis is scanty, and outcome following these vascular involvements is unknown. Aim To study the clinical profile, imaging findings, and details of vascular territory involved among patients admitted with cryptococcal meningitis and central nervous system infarct in a tertiary care center from India. And to compare the outcomes of patients of cryptococcal meningitis with or without central nervous system infarcts in terms of mortality and morbidity, Methodology A total of 151 patients with microbiologically proven cryptococcal meningitis over a time span of 11 years were retrospectively enrolled into the study. Of these, 66 patients met the inclusion criteria of having appropriate imaging of the brain. The presence of infarct in the imaging was analyzed by two independent radiologists. Patterns of central nervous system involvement and types of vascular injury were ascertained based on radiological parameters. Clinical parameters and outcomes of patients with and without infarcts were compared. Results Twenty (13%) of these patients had evidence of central nervous system infarcts on imaging. The mean age of patients with and without infarcts was 41 years and 38 years, respectively. Male predominance was present among both the groups. The presence of fever, neck stiffness, positive blood culture, and hydrocephalus in central nervous system imaging was similar among patients with or without infarct. Longer duration of illness, low sensorium at the time of presentation, low Glasgow Coma Scale score, presence of meningeal inflammation, cryptococcomas, and basal exudates in imaging were higher in patients with infarct. All the infarcts were of the lacunar type. Sixty percent of the cerebrovascular infarcts were acute in nature, 50% of these being multiple. Unilateral infarcts were seen in 70% of the patients. The most common site of infarct was the basal ganglia, others being distributed over the thalamus, frontal, temporal, parieto-occipital regions in the descending order. The presence of neurovascular involvement in the form of infarcts to the risk of morbidity and mortality had an odds ratio of 9.1 and 2.6, respectively. Conclusion Neurovascular involvement in chronic cryptococcal meningitis is a rare entity. These tend to present as multiple lacunar infarcts. Mortality and morbidity associated with these patients is higher when compared to patients who do not have infarcts. This result suggests that vascular injury plays a role in predicting outcome of patients with cryptococcal meningitis. Future studies are needed to understand the mechanism by which vascular events (infarcts) occur and result in poor outcome.

A 40-year-old gentleman from West Bengal, who is a farmer by profession, presented with easy fatigability, significant loss of weight, and asymptomatic, progressive nodulo-ulcerative lesions on his groins of 1 year duration. He gave no history of exploring caves or exposure to any large areas contaminated with bird droppings. General examination revealed firm, non-tender, discrete cervical, axillary, and inguinal lymphadenopathy. Systemic examination was within normal limits. Cutaneous examination showed dull erythematous, non-tender, and firm papules and nodules, few with central ulceration on both groins (Figures 1 and ​and22 ). There were no other skin lesions seen. The differentials considered were cutaneous tuberculosis, gummatous syphilis, atypical mycobacterial infection, nocardiosis, blastomycosis, sporotrichosis, and histiocytosis. A skin biopsy showed dense lymphoplasmahistiocytic infiltrates in the dermis with multinucleate giant cells containing budding yeasts (Figures 3 and ​and44 ). Fungal culture on Sabouraud Dextrose Agar medium showed growth of floccose, velvety, buff colored colonies on the obverse with brown pigmentation on the reverse, which were confirmed to be Histoplasma capsulatum (Figures 5​5–7). Blood investigations to look for immunosuppression including human immunodeficiency virus antibodies were negative. A computerized tomography (CT) scan of the abdomen showed large hypodense lesions in both adrenals. His chest X-ray and bone marrow examination were within normal limits. A diagnosis of disseminated histoplasmosis was made based on the skin biopsy showing intracellular yeasts, which on culture grew colonies of H. capsulatum, and the CT scan showing involvement of both adrenals. Figure 1. Ulcerated plaque in the groin of a patient with disseminated histoplasmosis. Figure 2. Erythematous, nodular lesions in the groin of a patient with disseminated histoplasmosis. Figure 3. Periodic acid–Schiff (PAS) histopathology. Photomicrograph showing PAS-positive yeasts in the deep dermis. Figure 4. Gomori methanamine silver stain histopathology. Photomicrograph showing Gomori methanamine silver-positive yeasts in the deep dermis. Figure 5. Sabouraud Dextrose Agar medium showing floccose, velvety, and buff colored colonies of Histoplasma capsulatum on the obverse. Figure 6. Sabouraud Dextrose Agar medium showing brown color on the reverse. Figure 7. Lactophenol cotton blue preparation from the culture plate showing septate, hyaline hyphae with large thick-walled spherical macroconidia with the external walls showing finger-like projections. Histoplasmosis is a highly infectious mycosis caused by an intracellular fungus H. capsulatum. Histoplasmosis is endemic in the Ohio and Mississippi River Valleys of the United States, central and South America, and Africa, but is less frequently reported in Asia and Europe.1 As pointed by Antinori,2 in India, this disease is predominantly seen along the Gangetic belt of northeast India. It can present as acute pulmonary, chronic pulmonary, acute progressive, chronic disseminated, and primary cutaneous forms. The risk factors for the acquisition of the disease include acquired immunodeficiency syndrome, primary and acquired immunodeficiency states, post transplant patients, and patients on immunosuppressive medications and extremes of age.3 In immunocompetent individuals, the disease usually manifests as an asymptomatic pulmonary infection. Disseminated histoplasmosis with cutaneous lesions is very rare in immunocompetent hosts.1 Oral ulcers are the most common mucocutaneous presentation in immunocompetent individuals with disseminated histoplasmosis.4 Cutaneous lesions of disseminated histoplasmosis are most commonly seen on the face, arms, and legs. The rarer sites of involvement, which have been reported include hands, feet, chest, back, penis, and perianal region.5 The oral lesions of histoplasmosis described in literature range from nodules, vegetating plaques to shallow or deep ulcers. The various cutaneous manifestations mentioned in literature include papules (including molluscum contagiosum–like lesions, acneiform eruptions), plaques, pustules, and nodules.5 This case is being reported to highlight the presentation of disseminated histoplasmosis at a rare site in an immunocompetent individual.

Erdheim-Chester disease (ECD) is a rare xanthogranulomatous disorder characterised by the proliferation of lipid laden histiocytes along with infiltration of various organs of the body. Although commonly presenting with bone pains secondary to bony infiltration, cardiac involvement in the form of periaortic fibrosis and pericardial involvement may be seen in a subgroup of patients. We report a case of ECD presenting as recurrent pericardial effusion along with pericardial tamponade.

A 63-year-old man presented with a pulsatile cutaneous horn on the nose and multiple angiomatous nodules on the gingiva and scalp, which appeared over 2 months. He had severe hypercalcaemia, lytic lesions in multiple bones and acute kidney injury. Excision biopsy from the gingival nodule showed a clear cell neoplasm. The bone marrow showed atypical cells with similar morphology. Imaging showed a 7 cmx7.5 cm mass at the upper pole of the left kidney with metastases to the bones, liver and lung. Immunohistochemistry was consistent with metastatic renal cell carcinoma. Renal cell carcinoma presenting as a cutaneous horn is extremely rare and to the best of our knowledge only one other case was found in the literature. There was visible regression in the size of the cutaneous horn and nodules following initiation of pazopanib therapy. However, he succumbed to his illness a month later.

Renal abscesses are most commonly caused by gram-negative bacilli. However, recently, all over the world, methicillin-resistant Staphylococcus aureus (MRSA) is an emerging cause of cutaneous and visceral infections. We report the case of a 31-year-old house wife who presented with clinical features of systemic lupus erythematosus (SLE).On evaluation of her prolonged fever and dysuria she was diagnosed to have a renal abscess secondary to MRSA. We report the first case report to the best of our knowledge, from India, describing a renal abscess due to MRSA in a SLE patient.