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Background: A consensus on the diagnostic utility of cerebrospinal fluid adenosine deaminase (ADA) for tuberculous meningitis (TBM) is lacking. Methods: Patients aged ≥12 years admitted with CNS infections were enrolled prospectively. ADA was measured with spectrophotometry. Results: We enrolled 251 TBM and 131 other CNS infections. The optimal cutoff of ADA was calculated at 5.5 U/l against microbiological reference standard with area under curve 0.743, sensitivity 80.7%, specificity 60.3%, positive likelihood ratio 2.03 and negative likelihood ratio 3.12. The widely used cutoff value 10 U/l had specificity 82% and sensitivity 50%. The discriminating power was higher for TBM versus viral meningoencephalitis than bacterial or cryptococcal meningitis. Conclusion: Cerebrospinal fluid ADA has a low-to-modest diagnostic utility.

Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19) pandemic. We conducted a prospective cohort study to evaluate the spectrum and outcomes of adult DKA during the pandemic and document differences in DKA patients with or without COVID-19. A total of 169 patients (mean age 44 years) were admitted at the Emergency Department of PGIMER, Chandigarh (India), from January 2020 to June 2021. The precipitating factors were noncompliance with antidiabetic therapy (77.5%), infections (62.7%), and noninfectious conditions (21.3%). Thirty-nine (23.1%) patients had COVID-19, including 31 with severe infection. DKA severity and resolution, ventilator requirement, hospital stay, and mortality were similar in the patients with or without COVID-19. In-hospital mortality was 39.6% (n = 67). The independent mortality predictors were ventilator requirement ( p-0.000), an infection trigger ( p-0.049), and hyperosmolarity ( p-0.048). DKA mortality is increased significantly during the pandemic.

A 14-year-old male patient presented to the emergency room with fever, loose stools, shortness of breath and swelling over the right popliteal fossa for 5 days. He had no significant past medical history and received all the vaccinations according to the immunisation schedule. He had an oxygen

Thrombotic disorders are characterized by the presence of elevated levels of detectable fibrin degradation products in the blood. The utility and sensitivity of quantitative D-Dimer assay to rule out the diagnosis of deep vein thrombosis is well established. We extrapolated this principle to evaluate the utility of D-Dimer assay in exclusion of cerebral venous sinus thrombosis (CVST). CVST is an important cause of cerebrovascular accidents in young patients and the residual neurological deficits can be minimized if correct therapy, i.e., anticoagulation is instituted in a timely manner. As advanced imaging modalities that are required for the diagnosis of CVST might not be readily available everywhere, it is important to have a sensitive biomarker which can guide clinicians to rule out the diagnosis with a reasonable confidence. We evaluated the patients admitted at a tertiary care center who underwent Computed tomography (CT) Venography/Magnetic resonance (MR) Venography of the brain with the clinical suspicion of CVST. After appropriate exclusion, a quantitative D-Dimer assay was performed in patients who had CVST on CT/MR Venography and was compared with those patients who did not. Receiver operating characteristic (ROC) analysis revealed that quantitative D Dimer had poor diagnostic accuracy for the differentiation of CVST from non CVST cases (Area under the curve = 0.694), but D-Dimer levels of

Objective Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India. Design A retrospective analysis of patients with in north India between 2010 and 2020. Methods The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed. Results The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005). Conclusion IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.

Background: A point-of-care diagnostic test for acute pancreatitis could help in early triage and management of this condition. Materials & methods: Urine trypsinogen dipstick test (UTDT) was performed in consecutive cases suspected to have acute pancreatitis and diagnostic accuracy calculated. Results: Of 187 patients, 90 were have acute pancreatitis and UTDT was positive in 61 (67.7%). In the 97 non pancreatitis cases, UTDT was positive in nine (9.3%). The sensitivity and specificity of UTDT for acute pancreatitis was 67.8% and 90.7%, respectively. In patients presenting within 3 days of abdominal pain, sensitivity and specificity were 72.7% and 91.8%, respectively. Discussion: While offering the possibility of a point of care diagnosis, the low sensitivity of UTDT could be a concern with its routine use.

Summary Objective Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients. Methods A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18–59 years were enrolled from July 2019 to December 2019. Results Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% vs. 78.1%, P = 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% vs. 89.0%, P = 0.043); however, headache (38.2% vs. 67.1%, P = 0.001), vomiting (18.2% vs. 35.6%, P = 0.030) and fever (80.0% vs. 91.8%, P = 0.052) were less common. Cerebrospinal fluid (CSF) abnormalities were less marked in older patients, with a significant difference in median total cells (70 vs. 110/µl, P = 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% vs. 35.2%, P = 0.012). Older patients had a significantly low survival rate (56.4% vs. 76.7%, P = 0.021). Conclusion Significant differences in clinical, CSF and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.

Background: The role of ascitic and serum levels of various tumour biomarkers in the discrimination of cause of ascites is not well established. Objective: To evaluate the role of serum and ascitic levels of tumor biomarkers (CA 72-4, CA 19-9, CEA and CA 125) in discrimination of cause of ascites. Methods: A prospective study was conducted in consecutive patients presenting with ascites. Serum and ascitic levels of CA 19-9, CA 125, CA 72-4 and carcinoembryonic antigen (CEA) were determined at the presentation. The patients with cirrhotic ascites, tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC) were eventually included in analysis. Results: Of the 93 patients (58 males, mean age 47 years) included, the underlying cause was cirrhosis in 31, PC in 42 and peritoneal tuberculosis in 20. The best cutoff for discriminating benign and malignant ascites for serum CEA, CA 19-9 and CA 72-4 were 6.7 ng/mL, 108 IU/mL and 8.9 IU/mL, respectively. The best cutoff for discriminating benign and malignant ascites for ascitic CA 125, CEA, CA 19-9 and CA 72-4 were 623 IU/mL, 8.7 ng/mL, 33.2 IU/mL and 7 IU/mL, respectively. Conclusion: The performance of single biomarker for the prediction of underlying PC is low but a combination of serum CA 19-9 and CA 72-4 best predicted the presence of peritoneal carcinomatosis. RESUMO Contexto: O papel dos níveis ascíticos e séricos de vários biomarcadores de tumores na discriminação da causa das ascites não está bem estabelecido. Objetivo: Avaliar o papel dos níveis séricos e ascíticos de biomarcadores tumorais (CA 72-4, CA 19-9, CEA e CA 125) na discriminação da causa das ascites. Métodos: Estudo prospectivo foi realizado em pacientes consecutivos que apresentaram ascite. Foram determinados níveis do soro e ascítico de CA 19-9, CA 125, CA 72-4 e antígeno carcinoembrínico (CEA). Os pacientes com ascites cirróticas, peritonite tuberculosa e carcinomatose peritoneal (CP) foram eventualmente incluídos na análise. Resultados: Dos 93 pacientes (58 homens, média de idade 47 anos) incluídos, a causa básica foi cirrose em 31, CP em 42 e tuberculose peritoneal em 20. O melhor corte para discriminação de ascites benignas e malignas para soro CEA, CA 19-9 e CA 72-4 foram 6,7 ng/mL, 108 UI/mL e 8,9 UI/mL, respectivamente. O melhor corte para discriminação de ascites benignas e malignas para CA 125 ascitico, CEA, CA 19-9 e CA 72-4 foram 623 UI/mL, 8,7 ng/mL, 33,2 UI/mL e 7 UI/mL, respectivamente. Conclusão: O desempenho do biomarcador único para a previsão do CP subjacente é baixo, mas uma combinação de soro CA 19-9 e CA 72-4 melhor previu a presença de carcinomatose peritoneal.

A knowledge of the extent and distribution of chronic comorbidity plays an essential role in providing appropriate care, and allocating health resources to the patients admitted to the emergency department. We performed a cross-sectional study to quantify the chronic diseases presenting in the Emergency Department of PGIMER, Chandigarh (India). Out of 205 patients, 133 (64.9%) had pre-existing comorbidity. Common were chronic kidney disease (29, 14.1%), chronic liver disease (23, 11.2%), diabetes mellitus (21, 10.2%), malignancy (20, 9.8%), cardiac diseases (17, 8.3%), and chronic obstructive pulmonary disease (9, 4.4%). The median Charlson comorbidity index score was 2 (range, 0–9). In-hospital mortality was 43 (21%) and was predicted by older age (median, 60 v. 50 years; p-value, 0.017). Deaths with previous stroke (66.6%), chronic obstructive pulmonary disease (55.6%), and diabetes (28.6%) were higher than cardiac (2.3%) and renal (6.9%) comorbidity. Increasing comorbidity requires a shift in existing models of emergency care.

A 48-year-old man presented with complaints of intermittent fever, dry cough, breathlessness and significant weight loss for 1 month. He also gave a history of increased urinary frequency and intermittent painless haematuria. Examination revealed bilateral cervical and axillary lymphadenopathy (figure 1A). Auscultation revealed fine inspiratory crepitations in bilateral lung fields. Chest X-ray was suggestive of diffuse involvement, illustrating miliary pattern in bilateral lung fields (figure 1B). Urine examination showed numerous red blood cells. Contrast-enhanced CT of kidney, ureter and bladder suggested a thickened bladder wall (figure 1C). A possibility of disseminated tuberculosis was considered and …

Background and aims The patients with diabetes mellitus (DM) have an increased incidence of both common and unusual infections. Despite an increasing prevalence of DM in India, local data on the epidemiology and clinical spectrum of associated infections are lacking. We aimed to investigate the spectrum, etiology, and outcome of infectious disorders in adult patients with DM admitted in a medical emergency. Methods A single-center retrospective observational study conducted between January 2018 to June 2019 in a tertiary care hospital in north India. Based on clinical presentation, radiological features, and microbiological or pathological evidence, 152 diabetic patients aged 12 years and above were diagnosed with the infectious syndrome. Results Urinary tract infection was the most prevalent infectious syndrome (32.2%), followed by pneumonia and empyema (26.3%), skin and soft tissue infections (6.6%), sepsis of unknown primary source (6.6%), pulmonary tuberculosis (4.6%), rhinocerebral infections (4.6%), infectious diarrhea (3.9%), and viral encephalitis (2.6%). The majority of the infections were community-acquired (94.7%). 80.3% of study cases had type 2 DM. The common presenting symptoms were fever (46.1%), dyspnea (27.6%), and altered sensorium (25.7%). Shock and diabetic ketoacidosis were frequent, and each was seen in 27.6% of cases. The mortality rate was 27.6% and was higher with sepsis of unrecognized source (50.0%) and lung infections (30.0%). The presence of shock was the independent predictor of mortality on a multivariant analysis (p-value 0.000). Conclusions Urinary tract and lung infections remain common in DM. Establishing a microbiological etiology and identification of the source are necessary steps to reduce mortality.

Related neurological adverse effects to metronidazole are rarely encountered in clinical practice despite its wide use as an antibacterial or antiparasitic agent. The neurotoxicity is not dose-dependent and is fully reversible with discontinuation of the drug. We describe a young man who was receiving metronidazole for an amoebic liver abscess and developed encephalopathy and seizures. Brain magnetic resonance imaging showed characteristic bilateral symmetrical cerebellar dentate hyperintensities.

A 28-year-old male was admitted with a history of sudden onset headache, multiple episodes of vomiting, gait disturbance with swaying toward right side, and blurring of vision for 2 days. The patient was conscious, cooperative, and oriented, and his vitals were normal. Bilateral gaze-evoked nystagmus was present. Motor and sensory examinations were within normal limit, and deep tendon reflexes were 2+ in all four limbs. Cerebellar examination reveals positive finger–nose test and dysdiadochokinesia on right side. A computed tomography of head showed acute intraparenchymal hemorrhage in right cerebellar hemisphere with effacement of fourth ventricle and mild hydrocephalus. Computed tomography angiography of cerebral vessels was normal. The coagulation profile (international normalized ratio: 1.02), renal function test, and liver function tests were within normal limit. Urine toxicology screen was positive for tetrahydrocannabinoid. The patient was diagnosed with right cerebellar bleed and cannabis abuse. The patient managed conservatively with intravenous mannitol and was discharged in hemodynamic stable condition. How to cite this article Pannu AK, Saroch A, Sharma N. Intracerebellar Hemorrhage in a Young Adult. Indian J Crit Care Med 2020;24(1):69–70.

2,4-D (2,4-dichlorphenoxyacetic acid) is a chlorphenoxy group pesticide. Its relative safety and broad leaf selectivity makes it a favourite herbicide of many home gardeners and agricultural workers. Severe systemic toxicity requiring hospital admission and intensive care usually occurs following intentional oral ingestion. 2,4-D poisoning is an under-recognised cause of a potentially lethal toxic syndrome, especially in low- and middle-income countries, where such compounds are widely used in farming and readily available in households. It warrants close monitoring and high-quality supportive care along with plasma alkalinisation or extracorporeal removal of the toxin. We present a short review on 2,4-D poisoning and describe two illustrative cases with significant oral ingestion resulted in early and rapidly developing systemic toxicity. Both patients were admitted to the intensive care unit; one patient was managed with alkaline diuresis and other case required three sessions of haemodialysis.

Background We aimed to retrospectively investigate the clinical and biochemical profile of Diabetic ketoacidosis (DKA) patients and various precipitating and prognostic factors. Methods This was a hospital-based retrospective observational study, conducted in a tertiary care hospital in north India, from March 2014 to March 2017. Results Among 50 patients who satisfied the study criteria, 10 (20%) had DKA as their first presentation. Most common symptoms were nausea and vomiting (74%). Noncompliance was the major precipitating cause in 26 cases (52%) followed by infections in 18 cases (36%). The mean value of blood sugar at presentation was 406.8 ± 130.4 mg/dl with serum ketone 5.38 ± 1.56 mmol/l and mean pH 7.128 ± 0.157 with severe DKA in 14 (28%) patients. Mean duration of hospital stay was 8.2.±5.0 days, and low hemoglobin (p = 0.019) and high pulse rate (p = 0.025) were independent predictors of a longer stay. Conclusion With intensive care, mortality did not occur; however, non-compliance remained the most common precipitating cause of DKA followed by infections.

Objective: To study the spectrum and outcome of severe scrub typhus in adult patients and to predict the hospital mortality by organ failure on admission. Methods: This was a prospective observational cohort study conducted between July 2017 and October 2020 at the medical emergency centre of PGIMER, Chandigarh, India. One hundred and twenty-six patients aged ≥13 years were diagnosed with scrub typhus. Severe disease was defined as the presence of organ failure based on the Sequential Organ Failure Assessment (SOFA) score on admission. Results: About two-thirds of the patients were from geographic regions outside the endemic sub-Himalayan belt. Fever (99.21%) and dyspnea (79.36%) were the most frequent complaints. Respiratory failure (81.75%) was the most common organ failure, followed by hepatic (52.38%), coagulative (47.62%), circulatory (33.33%), renal (21.43%), and cerebral dysfunction (13.49%). The median (Q1, Q3) SOFA score was 8 (6, 9), and 48.41% of the patients had a quick-SOFA score ≥2. Organ supports with invasive ventilation (40.48%), vasopressors (36.51%), and renal replacement therapy (7.14%) were frequently required. The in-hospital mortality was 11.90% and was independently predicted by circulatory and hepatic failures on multivariate logistic regression (OR 11.12, 95% CI 1.73-71.31 and OR 8.49, 95% CI 1.18-61.41, respectively). Conclusions: Most patients had pulmonary dysfunction; circulatory or hepatic failure on admission strongly predicts death.

Dengue is endemic in more than 100 countries, giving rise to an increased number of deaths in the last five years in the South-East Asian region. We report our findings from a retrospective study of adults admitted with confirmed dengue at our institution. We studied the clinical and laboratory parameters associated with mortality in these patients. Of the 172 hospitalised patients studied, 156 (90.69 %) recovered while 16 (9.3%) died. Univariate analysis showed altered sensorium on presentation, lower haemoglobin and haematocrit levels, higher serum creatinine, higher serum transaminase and lower serum albumin levels to be significantly associated with mortality in dengue. Further, using stepwise multivariate logistic regression, altered sensorium ( P = 0.006) and hypoalbuminemia ( P = 0.013) were identified as independent predictors of mortality in dengue. Identification of these parameters early in the course of disease should prompt intensification of treatment in dengue cases.

Tuberculosis (TB) is a major public health problem in developing countries. Lung is most common affected organ, however extra pulmonary tuberculosis (EPTB) is also not uncommon. The clinical manifestations of EPTB may be non-specific that mimics other diseases and is usually misdiagnosed. Therefore, high clinical suspicion of EPTB infection is important, especially in endemic areas. Here, we present a case of hard palate perforation that proved to be tuberculous in origin. The diagnosis was made by histo-pathological examination and positive TB Polymerase chain reaction (PCR).