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Objective: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP). Some in vitro data favour various combination antibiotic therapy. However, there is a need for more in vivo studies for the management of VAP caused by CRAB. This retrospective study was done to evaluate the effectiveness of various combination antibiotic therapy including sulbactam on outcomes of VAP caused by CRAB., Methods: Adult patients (age ≥18 years) diagnosed with VAP caused by CRAB were included. Patients with polymicrobial infections were excluded from the study. Patients with CRAB associated VAP who were given sulbactam based antibiotic combinations were observed for outcomes. The primary outcome was 28-day mortality after diagnosis of VAP caused by CRAB. Reduction in serum HsCRP (High sensitivity C-reactive protein) during treatment and requirement of inotropes were the secondary outcomes. Outcomes were compared between various sulbactam based antibiotic combination therapies., Results: A total of 103 patients were included. A total of 44 (42.7 %) patients received sulbactam and minocycline or sulbactam and polymyxin B dual antibiotic combination, and 59 (57.3 %) patients received sulbactam, polymyxin B and minocycline triple antibiotic combination. The percentage difference in 28 days mortality was 27.51 % (95 % CI 8.03 %-44.06 %; p = 0.005) in dual vs triple sulbactam based antibiotic combination therapy. The percentage difference in requirement of inotropes during therapy and HsCRP reduction after 7 days of therapy was 23.65 % (95 % CI 6.43 %-38.3 %; p = 0.007) and 25.1 % (95%CI 10.1 %-38.2 %; p < 0.001) respectively when compared between dual vs triple sulbactam based antibiotic combination therapy., Conclusion: Treatment with sulbactam, polymyxin B and minocycline combination antibiotic therapy was associated with significantly lower 28-day mortality. Moreover, the lower requirement of inotropes during treatment and a significant reduction in HsCRP level favours this combination antibiotic therapy in VAP caused by CRAB., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Deepak Kumar reports financial support was provided by Indian Council of Medical Research. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Indian Association of Medical Microbiologists. Published by Elsevier B.V. All rights reserved.)

Background: The landscape of Pseudomonas infective endocarditis (IE) is evolving with the widespread use of cardiac implantable devices and hospital-acquired infections. This systematic review aimed to evaluate the emerging risk factors and outcomes in Pseudomonas IE., Methods: A literature search was performed in major electronic databases (PubMed, Scopus, and Google Scholar) with appropriate keywords and combinations till November 2023. We recorded data for risk factors, diagnostic and treatment modalities. This study is registered with PROSPERO, CRD42023442807., Results: A total of 218 cases (131 articles) were included. Intravenous drug use (IDUs) and prosthetic valve endocarditis (PVE) were major risk factors for IE (37.6% and 22%). However, the prosthetic valve was the predominant risk factor in the last two decades (23.5%). Paravalvular complications (paravalvular leak, abscess, or pseudoaneurysm) were described in 40 cases (18%), and the vast majority belonged to the aortic valve (70%). The mean time from symptom onset to presentation was 14 days. The incidence of difficult-to-treat resistant (DTR) pseudomonas was 7.4%. Valve replacement was performed in 57.3% of cases. Combination antibiotics were used in most cases (77%), with the aminoglycosides-based combination being the most frequently used (66%). The overall mortality rate was 26.1%. The recurrence rate was 11.2%. Almost half of these patients were IDUs (47%), and most had aortic valve endocarditis (76%)., Conclusions: This review highlights the changing epidemiology of Pseudomonas endocarditis with the emergence of prosthetic valve infections. Acute presentation and associated high mortality are characteristic of Pseudomonas IE and require aggressive diagnostic and therapeutic approach., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Idiopathic CD4 lymphocytopenia (ICL) is an underdiagnosed immunodeficiency syndrome characterised by persistent low CD4 counts in the absence of HIV and other causes of lymphocytopenia. ICL patients are susceptible to opportunistic infections, with human papillomavirus, cryptococcal, and tuberculosis being the most common infections reported. Nocardiosis is rarely reported in patient with ICL., Case Presentation: We herein discuss a 46-year-old female presented with complaints of weight loss, low grade fever and cough with expectoration from last four months. The patient was diagnosed with pulmonary nocardiosis and aspergillosis co-infection four years back; in addition she also had ICL. Subsequently, the patient was lost in follow-up and readmitted four years later. Bronchoalveolar lavage sample shows the presence of acid-fast bacilli in modified gram stain, which later identified as Nocardia otitidiscaviarum by metagenomic next-generation sequencing. Her CD4 counts were still found low (298 cells/mm 3 ). After an initial improvement with trimethoprim-sulfamethoxazole (TMP-SMX), she was commenced on indefinite secondary prophylaxis., Conclusions: Nocardiosis without usual risk factors should be evaluated for ICL. This case emphasize the importance of periodic follow-up with CD4 count monitoring and secondary prophylaxis therapy to prevent recurrence or the emergence of new infections in ICL., Clinical Trial Number: Not applicable., (© 2024. The Author(s).)

Introduction. Mycotic aneurysms, characterized by vessel wall dilation resulting from infections including bacteria, fungi, and viruses, are a rare but severe consequence of systemic infections. The term 'mycotic' was coined by William Osler to describe the first instance of a fungal-induced infected aneurysm. These aneurysms, accounting for 0.6% of aneurysms in Western countries, carry a higher risk of rupture compared to uninfected aneurysms. While the femoral artery, aorta, and intracranial arteries are commonly affected, pathogens causing mycotic aneurysms vary across regions. Diagnostic challenges arise from nonspecific symptoms such as fever, and discomfort. To prevent the substantial morbidity and mortality associated with mycotic aneurysms, timely identification and treatment are paramount. We present a case series highlighting mycotic aneurysms caused by some rare pathogens - Salmonella Paratyphi A, Streptococcus pneumoniae , and Pseudomonas aeruginosa . Methods. This case series involves three patients diagnosed with mycotic aneurysms due to unusual pathogens. We describe each patient's clinical presentation, medical history, physical examination findings, laboratory results, imaging studies, and the diagnostic process leading to the identification of the causative pathogens. Results. The first patient is a 70-year-old gentleman who presented with a ruptured infra-renal abdominal aortic pseudoaneurysm caused by Salmonella Paratyphi A . The second patient is a 66-year-old gentleman with a Streptococcus pneumoniae -associated descending thoracic aortic pseudoaneurysm. The third patient is a 70-year-old gentleman with a ruptured descending thoracic aortic aneurysm with an occult aorto-oesophageal fistula due to Pseudomonas aeruginosa infection. The description highlights unique clinical features, laboratory findings, imaging results, and the management approaches undertaken in each patient. Conclusion. Mycotic aneurysms, pose diagnostic challenges due to their nonspecific symptoms. Early identification and intervention are essential to mitigate the severe complications associated with these aneurysms. The presented cases underscore the need for a comprehensive approach to diagnosis and management, ensuring optimal outcomes for patients affected by mycotic aneurysms., Competing Interests: The authors have no competing interests to declare that are relevant to the content of this article., (Copyright © 2024 The Authors.)

Introduction: Non-tuberculous mycobacterial (NTM) disease is an underdiagnosed condition that usually manifests as pulmonary infection. Extrapulmonary manifestations are rare and can be easily overlooked or misdiagnosed as tuberculosis or malignancy., Case Report: Herein, we present four cases of extrapulmonary NTM disease in immunocompetent patients. Patient 1 had bone marrow suppression secondary to NTM infection. Patient 2 was diagnosed with Mycobacterium abscessus meningitis, brain abscess and arachnoiditis. Patient 3 had pleural effusion, and fluid cytology revealed Mycobacterium fortuitum . Patient 4 was a 30-year-old male with cervical lymphadenopathy due to NTM. Two patients (case 2 and case 4) were initially diagnosed with tuberculosis but showed no response to anti-tubercular drugs. One patient (case 3) died within seven days of initiation of treatment. The rest of the patients (cases 1 and 2) showed clinical improvement with antimicrobial therapy for NTM species. Case 4 responded well to surgical excision without the need for antibiotics., Conclusions: Clinicians should be vigilant about the possibility of NTM disease. Early diagnosis is vital to prevent poor outcomes, particularly in the setting of disseminated infections., Competing Interests: Conflicts of interest: All authors – none to declare., (GERMS.)

Iliopsoas abscess is an infrequent condition characterized by the collection of pus in the iliopsoas compartment. The prevalence of the disease has been increasing in recent years with the emergence of various comorbidities and risk factors. The availability of newer imaging modalities has also improved the detection of new cases. Salmonellosis is an uncommon etiology in iliopsoas abscess and sacroiliitis. Most cases reported in the literature are associated with Staphylococcus aureus, Streptococci species, and Escherichia coli. Diabetes, hematological malignancies, HIV, and other immunocompromised states are important comorbidities/risk factors for iliopsoas abscess. We report a case of an 18-year-old male who presented with a history of fever and right hip pain for 10 days. Radioimaging revealed right sacroiliitis and iliopsoas abscess. Blood culture revealed pan-sensitive Salmonella typhi. After the prolonged course of antibiotics (intravenous ceftriaxone followed by oral levofloxacin), the patient improved with no further relapse in symptoms. Salmonella typhi should be an important differential of iliopsoas abscess in endemic regions after ruling out the common etiology such as S. aureus and Mycobacterium tuberculosis.

Enteric fever is a major contributor to rising health care costs in developing countries. Associated disease-related complications and drug resistance further compound this problem. Hemophagocytic lymphohistiocytosis (HLH) is an uncommon complication of enteric fever with high morbidity and mortality. This systematic review aimed to evaluate the clinical characteristics and treatment outcomes in enteric fever-associated HLH syndrome. We searched major electronic databases (PubMed, Google Scholar, and Scopus) to identify the cases of enteric fever associated with HLH from inception until June 2023. Prespecified data regarding clinical presentation, outcomes, and HLH therapy were collected. A total of 53 cases of enteric fever with HLH were included in the final analysis. The mean age of patients was 20 years, and the proportions of female and pediatric patients were 52.8% and 45.3%, respectively. The mean duration of illness was 10.4 days. A total of 39.6% of patients had enteric fever-associated complications; coagulopathy and encephalopathy were the most common (23.1% and 13.5%). The overall mortality rate was 9.4% in HLH. A total of 51% of patients received HLH-specific therapy (corticosteroids in 41.5% and intravenous immunoglobulin in 20.8% of patients). On multivariate analysis, high ferritin levels (≥5,000 ng/mL) were significantly associated with mortality (hazard ratio, 3.01; 95% CI = 0.62-14.12, P = 0.041). Enteric fever with secondary HLH is associated with high mortality. This review reveals the potential role of ferritin in disease prognosis. In cases with significantly elevated ferritin levels, the role of immunosuppressants or combination antibiotics should be explored.

Background: Among the two stent strategies, contemporary evidence favors double kissing crush technique (DKC) for complex unprotected distal left main bifurcation (UdLMB) lesions. However one of the major challenges to these lesions is side branch (SB) restenosis., Aims: Our aim was to identify optical coherence tomographic (OCT) characteristics that may predict SB restenosis (SBR) after UdLMB angioplasty using DKC technique., Methods: This was a single-center, retrospective study that included 60 patients with complex UdLMB disease, who underwent OCT-guided angioplasty using DKC technique. Angiographic follow-up was performed in all patients at 1 year to identify patients with SBR. Patients with SBR group were compared with patients without SBR (NSBR group) for OCT parameters during index procedure., Results: Twelve (20%) patients developed SBR at 1-year follow-up. The SBR group had longer SB lesion (18.8 ± 3.2 vs. 15.3 ± 3.7 mm, p = 0.004) and neo-metallic carinal length (2.1 vs. 0.1 mm, p < 0.001) when compared to the NSBR group. Longer neo-metallic carinal length was associated with the absence of the dumbbell sign, presence of hanging stent struts across the SB ostium on OCT of final MB pullback. On multivariate regression analysis, SB distal reference diameter (DRD) and SB stent expansion were identified as independent predictors of SBR with SB-DRD of ≤2.8 mm (area under curve-0.73, sensitivity-83.3%, and specificity-62.5%) and SB stent expansion of ≤89% (area under curve-0.88, sensitivity-83.3%, and specificity- 81.2%) as the best cut off values to predict SBR., Conclusions: SB DRD and SB stent expansion are the OCT predictors of future SBR after UdLMB angioplasty using DKC technique., (© 2023 Wiley Periodicals LLC.)

Introduction: Gram-positive bloodstream infections (BSIs) are an emerging health concern, especially in resource-limited settings. There is a paucity of data regarding the antimicrobial resistance (AMR) pattern of Gram-positive BSIs. The rise in multidrug-resistant infections further convoluted antibiotic selection. We aimed to assess the incidence, clinical and microbiological profile, antimicrobial resistance (AMR) and outcome in Gram-positive BSIs., Methods: This was a single-center prospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with culture-proven Gram-positive BSIs were included. Data were collected on all patients' demography, risk factors, AMR and clinical outcome., Results: A total of 210 clinically significant isolates were grown from July 2020 to December 2021. The incidence of Gram-positive BSIs was 29% (n=61); 55.9% of cases were healthcare-associated, while 44.1% were community-acquired. Coagulase-negative staphylococci (CoNS) were the major isolates (36.1%), followed by Enterococcus spp. (27.9%), methicillin-susceptible Staphylococcus aureus (MSSA) (18%) and methicillin-resistant Staphylococcus aureus (MRSA) (14.7%). The proportion of vancomycin and teicoplanin-resistant CoNS isolates was 13.6% and 19%. Among Enterococcus isolates, the proportion of vancomycin-resistant enterococci (VRE) and linezolid-resistant enterococci (LRE) were 11.8% and 5.9%. The overall mortality in Gram-positive BSIs was 42.6%. Older age, MRSA infection, septic shock, and high NLR were significantly associated with mortality. On the Cox regression model, age ≥65 years (HR: 2.5; 95%CI: 1.1-5.8; p=0.024) and MRSA infection (HR: 3.6; 95%CI: 1.5-8.5; p=0.021) were found as independent predictors of 30-day mortality., Conclusions: This study found substantial mortality with Gram-positive BSIs, especially MRSA infections. Moreover, the emergence of VRE and LRE is also alarming. Active surveillance of AMR and evaluation of mortality predictors may help overcome the therapeutic challenges in managing BSIs., Competing Interests: Conflicts of interest: All authors – none to declare., (GERMS.)

Background: CNS manifestations represent an emerging facet of NTM infection with significant mortality. Due to protean presentation and low index of suspicion, many cases are often treated erroneously as tubercular meningitis or fungal infections., Objectives: Literature on NTM CNS disease is scarce, with most available data on pulmonary disease. This systematic review aimed to evaluate the epidemiology, clinical presentation, diagnostic modalities, and predictors of outcome in CNS NTM infection., Methods: The literature search was performed in major electronic databases (PubMed, Google Scholar, and Scopus) using keywords "CNS," "Central nervous system," "brain abscess," "meningitis," "spinal," "Nontuberculous mycobacteria," "NTM". All cases of CNS NTM infection reported between January 1980 and December 2022 were included., Results: A total of 77 studies (112 cases) were included in the final analysis. The mean age of all patients was 38 years, with most patients male (62.5%). Mycobacterium avium complex (MAC) was the most common aetiology, followed by M. fortuitum and M. abscessus (34.8%, 21.4% and 15.2%, respectively). The disseminated disease was found in 33% of cases. HIV (33.9%) and neurosurgical hardware (22.3%) were the common risk factors. Intracranial abscess (36.6%) and leptomeningeal enhancement (28%) were the most prevalent findings in neuroimaging. The overall case fatality rate was 37.5%. On multivariate analysis, male gender (adjusted OR 2.4, 95% CI 1.2-7.9) and HIV (adjusted OR 3.7, 95% CI 1.8-6.1) were the independent predictors of mortality). M. fortuitum infection was significantly associated with increased survival (adjusted OR 0.18, 95% CI (0.08-0.45), p value 0.012)., Conclusions: Current evidence shows the emerging role of rapid-grower NTM in CNS disease. Male gender and HIV positivity were associated with significant mortality, while M fortuitum carries favourable outcomes., (© 2023. Japanese Society of Tropical Medicine.)

Acute gouty arthritis is a recognized complication of hyperuricemia and one of the most common forms of inflammatory arthritis in adults. Drug-induced hyperuricemia is increasingly prevalent in clinical practice. Diuretics, antitubercular medications, and immunosuppressants are the common drugs associated with hyperuricemia. Oral isotretinoin is the drug of choice for different forms of severe acne and is rarely associated with hyperuricemia. We present the case of a 30-year-old male with severe acne vulgaris who was prescribed isotretinoin and later presented with acute gout. The patient developed hyperuricemia and swelling of the right first metatarsophalangeal joint within two months of isotretinoin commencement. There was a second episode of similar joint swelling three months later, parallel to the isotretinoin rechallenge. The dose of isotretinoin was reduced with the addition of febuxostat. The patient did not develop further episodes and remained symptom-free without urate-lowering therapy.

A seroprevalence and molecular study was carried out in six districts of the state of Rajasthan, India to detect brucellosis in major livestock species. This study involves the testing of 3,245 livestock samples using the Rose Bengal Plate Test (RBPT), Indirect Enzyme-Linked Immunosorbent Assay (i-ELISA), and genus-specific polymerase chain reaction (PCR) markers for molecular diagnosis of the disease. In the tested samples, seroprevalence was 5.06% (CI: 1.96-8.15) using the RBPT test and 6.88% (CI: 1.98-11.78) using the i-ELISA test, while the cumulative seroprevalence (RBPT and i-ELISA) was 3.63% (CI: 0.44-6.83). The prevalence of the disease was 1.27% (CI: 0.56-3.11) when tested using molecular markers. The highest prevalence of brucellosis was detected in Cattle (7.00, 3.22%), followed by camels (5.50, 2.50%), buffalo (2.66, 0.00%), sheep (2.43, 0.41%), and goats (0.58, 0.23%) when serological (cumulative) and molecular diagnosis were considered preferred methods of detection. Cattle (3.22%) and camels (2.50%) also showed a high prevalence of disease when tested using molecular markers. The results of this study reveal that cattle, camel, and sheep brucellosis is prevalent in the study areas., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Meena, Sharma, Bishnoi, Soni, Jeph, Galav and Sharma.)

Introduction: Carbapenem resistant gram-negative bacterial infections are a growing concern worldwide. However, India is already in the era of a shortage of effective antibiotics for the management of these infections. Moreover, Difficult-to-Treat Resistance (DTR) gram-negative infections, which are not much studied, further complicate the scenario. This study emphasized the incidence and outcomes of DTR infections., Methodology: This is a single-center prospective observational study. The study included hospitalised patients aged ≥18 years with gram-negative bacterial bloodstream infections (GNBSI). Blood cultures with the growth of contaminants and/or single positive culture taken from the femoral site were excluded. Incidences of DTR infections and outcomes in the form of 30-day mortality were analysed., Results: Two hundred forty patients with GNBSI episodes were recorded. The Incidence of DTR GNBSI was 37.9% (91/240). Multivariate analysis found that Hospital-acquired infections, ICU admission and mechanical ventilation were independent risk factors for DTR GNBSI. The most common DTR GNB isolates were Klebsiella pneumoniae (31/49, 63.3%) and Acinetobacter baumannii (26/52, 50%). The adjusted relative risk of mortality was remarkably high in DTR GNBSI (aRR 3.9; 95% CI 1.9-7.9) as compared to CR+/DTR- GNBSI (aRR 0.3; 95% CI 0.1-1.0) and ESCR/CS GNBSI (aRR 1.1; 95% CI 0.5-2.4)., Conclusion: DTR GNB infections are growing concern in India and this need to be evaluated in multicentric studies. Moreover, DTR GNBSI was associated with significantly higher mortality and there is need of further empowerment of antibiotic stewardship practices., (Copyright © 2023 Indian Association of Medical Microbiologists. Published by Elsevier B.V. All rights reserved.)

Background: CNS actinomycosis is a rare chronic suppurative infection with non-specific clinical features. Diagnosis is difficult due to its similarity to malignancy, nocardiosis and other granulomatous diseases. This systematic review aimed to evaluate the epidemiology, clinical characteristics, diagnostic modalities and treatment outcomes in CNS actinomycosis., Methods: The major electronic databases (PubMed, Google Scholar, and Scopus) were searched for the literature review by using distinct keywords: "CNS" or "intracranial" or "brain abscess" or "meningitis" OR "spinal" OR "epidural abscess" and "actinomycosis." All cases with CNS actinomycosis reported between January 1988 to March 2022 were included., Results: A total of 118 cases of CNS disease were included in the final analysis. The mean age of patients was 44 years, and a significant proportion was male (57%). Actinomycosis israelii was the most prevalent species (41.5%), followed by Actinomyces meyeri (22.6%). Disseminated disease was found in 19.5% of cases. Most commonly involved extra-CNS organs are lung (10.2%) and abdomen (5.1%). Brain abscess (55%) followed by leptomeningeal enhancement (22%) were the most common neuroimaging findings. Culture positivity was found in nearly half of the cases (53.4%). The overall case-fatality rate was 11%. Neurological sequelae were present in 22% of the patients. On multivariate analysis, patients who underwent surgery with antimicrobials had better survival (adjusted OR 0.14, 95% CI 0.04-0.28, p value 0.039) compared to those treated with antimicrobials alone., Conclusion: CNS actinomycosis carries significant morbidity and mortality despite its indolent nature. Early aggressive surgery, along with prolonged antimicrobial treatment is vital to improve outcomes., (© 2023. The Author(s).)

Purpose: Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021., Methods: All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan., Results: A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement., Conclusion: Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes., Competing Interests: Declaration of Competing Interest None, (Copyright © 2023 SFMM. Published by Elsevier Masson SAS. All rights reserved.)

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome caused by macrophages and cytotoxic T cells with aberrant activation. The primary (genetic) form, which is caused by mutations that affect lymphocyte cytotoxicity and immune regulation, is most prevalent in children, whereas the secondary (acquired) form is prevalent in adults. Secondary HLH is commonly caused by infections or cancers, but it can also be caused by autoimmune disorders, in which case it is known as macrophage activation syndrome (MAS; or MAS-HLH). A 25-year-old female presented with a high-grade fever that lasted for two weeks. His laboratory results revealed pancytopenia, neutropenia, hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Based on the clinical presentation and laboratory findings, a provisional diagnosis of HLH has been made. A HLH protocol was utilized to treat the patient. During the course of hospitalization, systemic lupus erythematosus (SLE) was identified as the underlying cause. She improved dramatically after receiving an immunosuppressive regimen of etoposide, cyclosporine, and dexamethasone according to HLH protocol-2004 with individualized modifications. The clinician should be aware that HLH may be the initial manifestation of underlying SLE. Early diagnosis and aggressive, individualized treatment are the key to improving outcomes.

Background: Progress of the Integrated Disease Surveillance (IDSP) is of utmost importance to ensure optimal performance in Jodhpur, Rajasthan, India. The purpose of the study was to document the physical performance of the surveillance system on its core and support functions., Material and Methods: Mixed method study was conducted between September 2020 to October 2020. Quantitative data was collected from the district IDSP unit of the Chief Medical and Health Office (CMHO) for various blocks of Rajasthan using syndromic, presumptive, and laboratory-confirmed reporting formats. Ethical clearance was obtained from the Institutional Ethical Committee of AIIMS, Jodhpur., Results: Rajasthan reported outbreaks between 0.55 to 1.2% of the national average between 2015-2019. Acute respiratory infections, fever of unknown origin, and acute diarrhea were the leading diseases under the presumptive reporting format. Major syndromic cases reported were cough with/without fever (more than three weeks) and fever less than seven days with the rash. Laboratory-confirmed Dengue, Malaria, and hepatitis were reported more in urban Jodhpur., Conclusion: Despite some pitfalls, IDSP has made satisfactory improvements in its core and support functions in the Jodhpur district of Rajasthan. The number of preventable morbidity and mortality cases associated with notifiable infectious diseases in our country can be effectively countered by strengthening the IDSP reporting system., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Community Medicine.)

The emergence of Mucorales infections is an urgent global public health threat rapidly disseminating during the current COVID-19 pandemic. Invasive mucormycosis carries significant morbidity and mortality; this is further compounded by the lack of newer effective antifungals on the horizon. Liposomal Amphotericin (L-AMB) is currently considered the cornerstone of antifungals therapy against mucormycosis; However, two decades later (since the introduction of L-AMB), the outcome remains dismal. Furthermore, adverse events related to therapeutic doses of L-AMB are also a hindrance. There is an imperative need for an alternative therapeutic approach to reduce the high mortality. One such approach is to combine the amphotericin with other agents (e.g., caspofungin, posaconazole, isavuconazole, and iron chelators) that can work synergistically or help in reducing the therapeutic doses of L-AMB. This review aims to highlight the various treatment approaches by gathering the clinical evidence from the literature and considering all potential pharmacological combinations that can provide the direction for future studies., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest., (Copyright © 2022 SFMM. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Hepatitis B virus (HBV) is known as a metabolovirus due to its impact on lipid and glucose metabolism in the liver. Previous literature showed a trend of hypolipidemia and reduced risk of metabolic syndrome in hepatitis B surface antigen-positive patients. However, data from the Indian population are lacking. We evaluate the relation of lipid profile with HBV infection and severity of liver disease., Materials and Methods: This was an observational cross-sectional study in which 50 patients with chronic hepatitis B and 43 anthropometrically matched seronegative controls were enrolled. Demographical, clinical, and laboratory data including lipid profile (high-density lipoprotein [HDL], low-density lipoprotein [LDL], triglycerides, and total cholesterol [TC]) were collected. Seropositive patients were categorized based on prognostic models (model for end-stage liver disease [MELD] and Child-Pugh score) for further analysis., Results: Our study revealed significant low levels of serum TC, HDL, and LDL cholesterol in hepatitis B patients compared to seronegative controls (133.06 vs. 162.39, 35.56 vs. 43.65, and 76.62 vs. 99.95 mg/dl respectively, P < 0.05). The patients with high MELD and Child-Pugh score were associated with hypolipidemia. Significant low levels of LDL and TC were observed in Child-Pugh class C in comparison to class A (94.8 vs. 149.2 and 50.6 vs. 87.9 mg/dl respectively, P < 0.05)., Conclusions: A significant reduction in various lipid parameters was seen with chronic hepatitis B. Furthermore, prognostic score (high MELD and Child-Pugh score) were associated with hypolipidemia., Competing Interests: None

Cases with SARS-CoV-2 RT-PCR negative pneumonia are an understudied group with uncertainty remaining regarding their treatment approach. We aimed to compare the clinical and radiological characteristics of RT-PCR positive and clinically diagnosed RT-PCR negative COVID-19. This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with suspicion of COVID-19 with SARI (severe acute respiratory infections) who were subjected to RT-PCR testing (nasal/oropharyngeal swab) were included. Based on RTPCR results, patients were categorized and compared for demographic, clinical, and biochemical characteristics and outcomes. Out of 500 patients, 339 (67.8%) found RT-PCR positive. Except for the radiological findings, both groups differ in clinical presentation, disease severity (inflammatory markers), and outcome. RT-PCR-positive patients had raised ferritin, NLR (Neutrophil-Lymphocyte ratio), LDH, and high mortality compared to the swab-negative group. In-hospital mortality was also significantly high in RT-PCR positive group (HR=1.9, 95% CI=1.4-2.5, p=0.001). On multivariate analysis, NLR, ferritin, and d-dimer were the independent predictors of mortality in RT-PCR-positive (p=0.038, 0.054, and 0.023). At the same time, raised TLC (total leukocyte count) and procalcitonin were the risk factors for poor outcomes in RT-PCR-negative patients (p=0.041 and 0.038). We found significantly raised ferritin, NLR, and LDH levels and increased mortality in RT-PCR positive patients compared to RT-PCR negative. Incorporating clinical features, radiological, and biochemical parameters could be prudent while managing the RT-PCR-negative patients., Competing Interests: Conflicts of interest The authors declare that they have no conflict of interest., (Copyright © 2016 - 2022 InfezMed.)

Stroke is a devastating and disabling cerebrovascular disease with some amount of residual deficit leading to economic loss. In 2010, the absolute numbers of people with first stroke (16.9 million), stroke survivors (33 million), stroke related deaths (5.9 million),National Commission on Macroeconomics and Health, estimated 1.67 million stroke cases in India by the year 2015, suggesting that stroke will be a rising epidemic in India in the near future. This may be due to the high prevalence of hypertension, diabetes, dyslipidemia., Material: Cross - Sectional observational type of study. Study Subject:-Study of 100 cases of cerebrovascular stroke correlating clinical presentation with radiological study., Sample Size: -100 Patients., Observation: In the present study, types of the stroke were divided as Ischemic Stroke and Hemorrhagic Stroke with 80 (80%) and 20 (20%) respectively, out of 100 patients of stroke 54(54%) were from older age group of 51-80 years and 46 (46%)patients were from younger and adult age group of 18-50 years, male patients were predominantly higher 73 (73%) as compared to female 37 (37%) patients, most common presenting symptom was hemiplegia 82(82%) followed by speech disorder 68(68%) and altered sensorium 56(56%),most common anatomical site of infarction was frontal 32(40%) followed by parietal 30(37.5%), temporal 16(20%) and internal capsule 14(17.5%). Other less commom sites were thalamus 10(12.5&),midbrain 10(12.5%), pons 8(10%) and medulla 6(7.5%). Among haemorrhagic stroke, most common anatomical site of haemorrhage were basal ganglia 10(50%). thalamus 8(40%), pons 6(30%) and cerebellum 4(20%)., Conclusion:

• Ischemic stroke has higher incidence than hemorrhagic stroke.
• The prevalence of stroke increases with age.
• Males were more affected than females in ischemic stroke but for hemorrhage, incidence was almost equal.
• Hypertension was amongst leading risk factors for both types.
• Total cholesterol and high level of serum fibrinogen were most common biochemical abnormalities in stroke.

The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4-9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24-6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09-0.42; p < .001) compared to those treated with antifungals alone. Recurrence of FE was reported in 10.4% of patients. In conclusion, FE carries significant mortality, particularly in immunodeficient and Aspergillus endocarditis. We advocate the use of surgery combined with antifungals to improve clinical outcomes., (© 2021 Wiley-VCH GmbH.)

Aspergillus is a ubiquitous ascomycete that can cause a variety of clinical presentations depending on immune status. Central nervous system aspergillosis is a fatal disease with non-specific clinical features. The aim of this systematic review was to evaluate the epidemiology, clinical features, diagnosis and therapeutic interventions in CNS aspergillosis patients. We also aimed to examine the possible predictors of mortality in neuroaspergillosis. Literature search was performed in Medline, PubMed, and Google scholar and all patients≥18 years with proven CNS aspergillosis were included. A total of 175 articles (235 patients) were included in the final analysis. Their mean age was 51 years and the majority were male (57.4%). Overall case-fatality was 45.1%. Aspergillus fumigatus was the most common species (70.8%) followed by A. flavus (18.6%). Corticosteroids (22.6%), malignancy (19.1%) and diabetes mellitus (14%) were the most common risk factors. Neuroimaging findings included cerebral abscess (70.2%), meningitis (14%), infarction (13.2%) and mycotic aneurysm (8.9%). Disseminated disease (29.2% vs 17.8%, p 0.03), CSF hypoglycorrhachia (48.1% vs 22.2%, P: 0.001) and heightened CSF galactomannan (3.62 vs 2.0ng/ml, p 0.05), were the factors associated with poor outcome in neuroaspergillosis. Persons infected with Aspergillus flavus (13.1% vs 3.1%, P: 0.01), and having been treated with Voriconazole (51.9% vs 29.2%, P: 0.004) were more likely to survive. Our review will provide insight into the different spectrums of CNS aspergillosis. Notwithstanding the promising role of Voriconazole, future work is required to ascertain the role of combination antifungal therapy., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Bloodstream infections (BSIs) are an emerging cause of significant morbidity and mortality in severe Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence, clinical profile and outcome of BSIs in critically ill COVID-19 patients., Methods: This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age > 18 years) with reverse-transcription polymerase chain reaction (RT-PCR) confirmed COVID-19 admitted in the intensive care unit (ICU) were included. Hospital electronic records were searched for demographic data, time of bloodstream infection since admission, clinical profile, antimicrobial resistance pattern and clinical outcome of all patients who developed BSIs., Results: Out of 750 patients admitted in COVID ICU, 8.5% developed secondary BSIs. All severe COVID-19 patients who developed BSIs succumbed to illness. A significant proportion of BSIs were Gram-negative pathogens (53/64, 82.8%). Acinetobacter baumannii was the commonest isolate, followed by Klebsiella pneumoniae (32.8% and 21.9%, respectively). Multidrug-resistance organisms (MDRO) were found in 57.8% of the cases. The majority of MDRO belonged to K. pneumoniae and Enterococcus groups. The proportion of Gram-negative bacteria resistant to carbapenems was 47.2% (25/53). On multivariate analysis, raised total leukocyte counts, mechanical ventilation and presence of comorbidities were significantly associated with the incidence of BSIs., Conclusion: We found a significant prevalence of Acinetobacter baumannii in COVID-19 associated BSIs. The presence of comorbidities raised leukocyte counts and mechanical ventilation should alarm clinicians for possible BSIs. The timely initiation of empirical antibiotics and rapid de-escalation is vital to improve the outcome. At the same time, strict compliance of infection control practices should be accomplished to reduce the occurrence of MDRO., (© 2021. The Author(s).)

Introduction Lack of specific clinical features makes the diagnosis of pulmonary nocardiosis difficult. A high index of suspicion is required for diagnosis especially in cohorts with pre-existing risk factors. This study aimed to study the clinical and radiological characteristics and outcomes in patients with pulmonary nocardiosis. Methods This was a retrospective observational study. Data of confirmed cases with pulmonary nocardiosis were collected from a digital patient management system. Results A total of eight cases of pulmonary nocardiosis were included. The mean age of patients was 50 ± 14.3 years with a female preponderance (62.5%). The most common co-morbidity was chronic lung disease (37.5%). The common clinical feature of pulmonary nocardiosis was cough with expectoration (50%) and the mean duration of symptoms was 18 days. The common radiological (CT thorax) findings were consolidation, bronchiectasis, mediastinal lymphadenopathy, and nodularity (50% each). One patient had an extension of pulmonary disease in the chest wall. Microbiological detection of Nocardia spp. was done in sputum samples (50%) and in bronchoalveolar lavage (BAL) samples (50%). Culture was positive in two BAL samples. Intravenous empirical antibiotics in combination with oral trimethoprim-sulfamethoxazole double standard (15 mg/kg trimethoprim) were started at the time of diagnosis. Ceftriaxone and amikacin were commonly used antimicrobials. Conclusion Nocardia spp. commonly causes disease in patients with pre-existing chronic disease. A high index of suspicion is required in patients with subacute to chronic respiratory symptoms, raised inflammatory markers, and the absence of common respiratory pathogens in evaluation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Yadav et al.)