Algorithmic Approach to Benign Prostatic Hyperplasia: An Indian Perspective.

Benign prostatic hyperplasia (BPH) is a prevalent condition affecting aging men, necessitating a comprehensive and evidence-based approach to diagnosis and management. This manuscript, through the summarization of the latest evidence, aims to establish a consensus among clinicians regarding optimal strategies for diagnosing and managing BPH, to improve patient care and outcomes in clinical practice. A panel of urologists conducted a comprehensive review of the literature by searching various databases and search engines (PubMed, Google Scholar, and Cochrane databases). They identified relevant studies on the diagnosis and management of BPH. The literature was summarized and analyzed to develop 14 statements. The panel utilized a Delphi methodology over two rounds (R1 and R2) to reach a consensus on the statements, considering both the literature evidence and expert opinions. The expert panel reached a consensus on 14 statements addressing diverse aspects of BPH, including tailored therapies for different patient profiles and the necessity for a unified diagnosis and management algorithm to enhance patient outcomes. In conclusion, a unified approach to diagnosing and managing BPH promotes consistent and effective patient care. Proper drug selection, considering factors like efficacy and patient-specific characteristics, is crucial for managing BPH. This approach optimizes treatment outcomes and improves the quality of life for BPH patients.

Cardiovascular Complications of Obstructive Sleep Apnea in the Intensive Care Unit and Beyond.

Obstructive sleep apnea (OSA) is a common disease with a high degree of association with and possible etiological factor for several cardiovascular diseases. Patients who are admitted to the Intensive Care Unit (ICU) are incredibly sick, have multiple co-morbidities, and are at substantial risk for mortality. A study of cardiovascular manifestations and disease processes in patients with OSA admitted to the ICU is very intriguing, and its impact is likely significant. Although much is known about these cardiovascular complications associated with OSA, there is still a paucity of high-quality evidence trying to establish causality between the two. Studies exploring the potential impact of therapeutic interventions, such as positive airway pressure therapy (PAP), on cardiovascular complications in ICU patients are also needed and should be encouraged. This study reviewed the literature currently available on this topic and potential future research directions of this clinically significant relationship between OSA and cardiovascular disease processes in the ICU and beyond.

Extragonadal mixed germ cell tumor of the seminal vesicle.

Primary malignancies of the seminal vesicles are rare. Presentation of extragonadal germ cell tumor in the seminal vesicle is even rarer. We report a case of a 26-year-old male who presented with hematuria and lower urinary tract symptoms, which on imaging turned out to be a right seminal vesicle mass. The diagnosis of mixed germ cell tumor with yolk sac tumor and teratoma was made on the initial evaluation by transrectal ultrasound-guided biopsy which showed the characteristic histomorphology and immunohistochemistry profile. The patient underwent chemotherapy followed by radical pelvic exenteration. The patient is doing well with no evidence of distant metastasis in positron emission tomography/computed tomography of 1-year posttreatment.

Non-urological cause of bilateral hydroureteronephrosis.

Bilateral hydroureteronephrosis in a patient with central diabetes insipidus is a rare condition. This rare presentation poses unique diagnostic and therapeutic challenges. Herein, we report a case of diabetes insipidus associated with bilateral hydroureteronephrosis and discuss its clinical and radiographic findings with a special focus on the urological aspects. Dramatic improvement, both clinically and radiologically, was seen after the administration of desmopressin therapy.

Prospective analysis of laparoscopic versus open radical nephrectomy for renal tumours more than 7 cm.

AIMS: To analyse the feasibility of laparoscopic radical nephrectomy (LRN) for renal tumours >7 cm and to compare the operative and oncologic outcomes with open radical nephrectomy (ORN). SETTINGS AND DESIGN: This was a prospective, observational, comparative study. SUBJECTS AND METHODS: The study was conducted at a tertiary care super-speciality hospital. All the patients who underwent radical nephrectomy for >7 cm renal tumours during a period of 2 years (April 2012 to May 2014) were included in the study. Thirty patients were included in each ORN and LRN group. Pre-operative, intra-operative and post-operative data for all these patients were collected and analysed. STATISTICAL ANALYSIS USED: Statistical Package for the Social Sciences (SPSS, version 11.0 for Windows, Chicago, IL). RESULTS: Mean age of patients in ORN and LRN groups was 57.3 ± 6.1 years and 54.9 ± 5.7 years, respectively (P = 0.220). As compared to ORN, LRN had less drop in post-operative haemoglobin (1.39 ± 0.55 g/dl vs. 4.07 ± 1.023 g/dl, P < 0.05), less drop in haematocrit value (4.7 ± 3.25% vs. 9.5 ± 5.13%, P < 0.05), less analgesic requirement for tramadol hydrochloride (165 ± 74.5 mg vs. 260 ± 181.66 mg) and less mean hospital stay (4.2 days vs. 6.1 days, P < 0.05). There was no statistically significant difference in post-operative complication rate and recurrence-free survival over a median follow-up of 17 months (93.9% - LRN vs. 90% - ORN). CONCLUSIONS: LRN for large renal tumours is feasible and achieves oncologic outcomes similar to that obtained with ORN.

Laparoscopic Retrograde Nephrectomy as a Troubleshooting Technique to Prevent Open Conversion: The Technique Description With a Review of 40 Cases.

Introduction Laparoscopic nephrectomies are safe, with low complication rates in skilled hands. However, traditional approaches may be unsuitable for conditions such as post-renal abscesses, long-standing urinomas, non-functioning kidneys post-pyeloplasty, pyelolithotomies, post-partial nephrectomy recurrences, tuberculous kidneys, pyelonephritis, and redo-renal surgeries. This study describes a modified retrograde nephrectomy technique and its outcomes in 40 cases. Methods We reviewed 40 cases where the retrograde nephrectomy technique was used. Surgeons opted for this method based on intraoperative findings and initial difficulties in accessing the lower pole area. Results Traditional dissection was challenging due to adhesions in the lower pole. The retrograde technique, starting from the renal hilum, allowed early ligation of renal arteries and veins, reducing bleeding risks and facilitating safer caudal dissection. Conclusions The retrograde nephrectomy technique offers a safer and more efficient alternative for complex nephrectomies. Early vascular control minimizes hemorrhage risk, making it a valuable method in challenging renal surgeries.

Study of cognitive functions and their association with depression in type II diabetes mellitus.

Introduction: Individuals with diabetes have higher risk of developing depression, cognitive impairment, and dementia compared to those who do not have diabetes. The present study aims to assess the level of cognitive functions and the presence of depression in diabetes patients and healthy controls. The study also explores the level of cognition among the normal control, diabetes without depression, and diabetes with depression. Methods: In the present study, the presence of depression and the level of cognitive functions of 59 cases of diabetes mellitus type-2 were compared with an age- and gender-matched control group of 40 individuals. Clinical and demographic details were recorded on a semi-structured performa. Montreal Cognitive Assessment (MoCA) and Patient Health Questionnaire-9 (PHQ-9) were applied to both diabetes patients and healthy controls to assess the level of cognitive functions and the presence of depression, respectively. Results: On applying odds ratio (OR), it was observed in the present study that there were 93.50% more chances [OR 1.935 with 95% confidence interval (CI) being 0.481-7.789] of depression among diabetic cases as compared to the control group. Similarly, the chance of MoCA score being less than 26 was twice among the diabetic group as compared to the control group (OR 2.208 with 95% CI being 0.702-6.946). On application of the Chi-square test, the association of depression was significant with HBA1C level, level of education, and presence of complications. Conclusions: Patients with diabetes had almost double the risk of developing depression and poor cognitive functions as compared to the healthy control. High HbA1C level, level of education, and presence of complication in diabetes had a positive statistical association with depression. Thus, it is advisable to investigate patients with diabetes for the presence of depression and cognitive dysfunction by applying simple tools.

Association of estimated plasma volume with new onset acute kidney injury in hospitalized COVID-19 patients.

PURPOSE: To explore the association of estimated plasma volume (ePV) and plasma volume status (PVS) as surrogates of volume status with new-onset AKI and in-hospital mortality among hospitalized COVID-19 patients. MATERIALS AND METHODS: We performed a retrospective multi-center study on COVID-19-related ARDS patients who were admitted to the Mayo Clinic Enterprise health system. Plasma volume was calculated using the formulae for ePV and PVS, and longitudinal analysis was performed to find the association of ePV and PVS with new-onset AKI during hospitalization as the primary outcome and in-hospital mortality as a secondary outcome. RESULTS: Our analysis included 7616 COVID-19 patients with new-onset AKI occurring in 1365 (17.9%) and a mortality rate of 25.96% among them. A longitudinal multilevel multivariate analysis showed both ePV (OR 1.162; 95% CI 1.048-1.288, p=0.004) and PVS (OR 1.032; 95% CI 1.012-1.050, p=0.001) were independent predictors of new onset AKI. Higher PVS was independently associated with increased in-hospital mortality (OR 1.038, 95% CI 1.007-1.070, p=0.017), but not ePV (OR 0.868, 95% CI 0.740-1.018, p=0.082). CONCLUSION: A higher PVS correlated with a higher incidence of new-onset AKI and worse outcomes in our cohort of hospitalized COVID-19 patients. Further large-scale and prospective studies are needed to understand its utility.

Association of antibiotics with the outcomes in COVID-19 pneumonia patients with elevated PCT levels.

OBJECTIVE: To assess antibiotics impact on outcomes in COVID-19 pneumonia patients with varying procalcitonin (PCT) levels. METHODS: This retrospective cohort study included 3665 COVID-19 pneumonia patients hospitalized at five Mayo Clinic sites (March 2020 to June 2022). PCT levels were measured at admission. Patients' antibiotics use and outcomes were collected via the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry. Patients were stratified into high and low PCT groups based on the first available PCT result. The distinction between high and low PCT was demarcated at both 0.25 ng/ml and 0.50 ng/ml. RESULTS: Our cohort consisted of 3665 patients admitted with COVID-19 pneumonia. The population was predominantly male, Caucasian and non-Hispanic. With the PCT cut-off of 0.25 ng/ml, 2375 (64.8 %) patients had a PCT level <0.25 ng/mL, and 1290 (35.2 %) had PCT ≥0.25 ng/ml. While when the PCT cut off of 0.50 ng/ml was used we observed 2934 (80.05 %) patients with a PCT <0.50 ng/ml while 731(19.94 %) patients had a PCT ≥0.50 ng/ml. Patients with higher PCT levels exhibited significantly higher rates of bacterial infections (0.25 ng/ml cut-off: 4.2 % vs 7.9 %; 0.50 ng/ml cut-off: 4.6 % vs 9.2 %). Antibiotics were used in 66.0 % of the cohort. Regardless of the PCT cutoffs, the antibiotics group showed increased hospital length of stay (LOS), intensive care unit (ICU) admission rate, and mortality. However, early de-escalation (<24 h) of antibiotics correlated with reduced hospital LOS, ICU LOS, and mortality. These results were consistent even after adjusting for confounders. CONCLUSION: Our study shows a substantial number of COVID-19 pneumonia patients received antibiotics despite a low incidence of bacterial infections. Therefore, antibiotics use in COVID pneumonia patients with PCT <0.5 in the absence of clinical evidence of bacterial infection has no beneficial effect.

Supine Versus Prone Percutaneous Nephrolithotomy (PCNL): A Single Surgeon's Experience.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is one of the greatest advances in the field of urology and has been considered the gold standard in the treatment of renal calculi of more than 2 cm in size. While both the supine and prone positions offer their unique advantages, it is still being debated which position offers the most in terms of surgical outcomes. We have evaluated the two approaches in terms of operative time, success rate, stone clearance rate, safety, and complications. METHODS: This prospective cohort study was done in the urology department of a tertiary care center in South India between January 2018 and October 2020. A total of 166 patients, with 83 in supine and 83 in prone positions, were included in the study. RESULTS: Both groups were matched in terms of age, body mass index, stone size and location, co-morbidities, medications taken, presence of diverticular stone, history of surgery, and baseline creatinine level. Mean operative time and pain scores were noted to be less in supine position as compared to prone. Ease of puncture was superior in supine position. Stone residue was noted to be higher in supine PCNL as well. CONCLUSION: Supine PCNLs are preferred in high-risk patients while the prone position is preferred in bilateral PCNLs, complex anatomy, or larger stone burden.

The Impact of En-bloc Transurethral Resection of Bladder Tumour on Clinical, Pathological and Oncological Outcomes: A Cohort Study.

Background En-bloc transurethral resection of bladder tissue (ETURBT) has recently been proposed as a good alternative technique to trans-urethral resection of bladder tissue (TURBT) in terms of outcomes for bladder carcinoma. This study aims to assess the effectiveness of the technique in terms of clinical, pathological and oncological outcomes. Methodology In this prospective study, data was collected from patients who underwent ETURBT for bladder space-occupying lesions between June 2021 and June 2022. Demographic characteristics, tumour characteristics, and postoperative outcomes were recorded. Results A total of 52 patients were studied with the majority being male and a mean age of 50.87 years. Smoking was recorded in 22 (38.5%) patients and 8 (15.4%) were on antiplatelet therapy. The majority fell in the American Society of Anesthesiology (ASA) class I (59.6%). Most of the tumours were solitary (90.4%), primary (82.8%), papillary architecture (73.1%), and between 1-3 cm in size. The lateral wall was the most common position, and detrusor muscle was seen in 98.1% of the specimens. T1 stage (57.7%) and low grade (67.3%) were the common characteristics noted. 76.9% of the ETURBT was conducted using monopolar cautery. Recurrence was noted in 3 (5.8%) and bladder perforation in 1 patient (1.9%). Cautery artifact was seen in six patients (11.5%) and obturator jerk in nine patients (17.3%). Conclusion Our study suggests that ETURBT is a technique with a good success rate for bladder tumours less than 3 cm in size. The benefits include high chances of detrusor sampling while minimising crush artefacts and cautery damage. Specimen retrieval was challenging when the bladder tumour was solid and over 2 cm.

COVID-19-associated MRSA infective endocarditis and mitral valve perforation: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic, leading to significant morbidity and mortality. The interplay between COVID-19 and other medical conditions can complicate diagnosis and management, necessitating further exploration. CASE PRESENTATION: This case report presents a patient with COVID-19 who developed infective endocarditis (IE) and mitral valve perforation caused by methicillin-resistant Staphylococcus aureus on a native mitral valve. Notably, the patient did not exhibit typical IE risk factors, such as intravenous drug use. However, he did possess risk factors for bacteremia, including a history of diabetes mellitus and recent steroid use due to the COVID-19 infection. The diagnosis of IE was crucially facilitated by transesophageal echocardiography. CONCLUSIONS: This case highlights the potential association between COVID-19 and the development of infective endocarditis. Prompt evaluation using transesophageal echocardiography is vital when there is a high suspicion of IE in COVID-19 patients. Further research is required to elucidate the precise relationship between COVID-19 and IE.

Quality Improvement Initiative in a Community Hospital to Reduce Central Line Device Utilization Rate.

Background The intensive care unit (ICU) in a community hospital in southwest Minnesota saw a steady increase in central line-associated bloodstream infections (CLABSI) and an increase in the utilization of central lines. The baseline CLABSI rate was 11.36 at the start of the project, which was the highest in the last five years. The corresponding device utilization rate (DUR) was 64%, which increased from a pre-COVID pandemic rate of 45%. Aim The aim of this project was to decrease the ICU DUR by 37.5% from a baseline of 64% to 40% within six months without adversely impacting staff satisfaction. Methods A multidisciplinary team using the define, measure, analyze, improve, and control (DMAIC) methodology reviewed the potential causes of the increased use of central lines in the ICU. The team identified the following major causal themes: process, communication, education, and closed-loop feedback. Once the root causes were determined, suitable countermeasures were identified and implemented to address these barriers. These included reviewing current guidelines, enhanced care team rounding, staff education, and the creation of a vascular access indication algorithm. The team met biweekly to study the current state, determine the future state, evaluate feedback, and guide implementation. Results The pandemic saw a surge in the number of severely ill patients in the ICU, which may have caused an increase in the DUR. The project heightened the awareness of the increased DUR and its impact on the CLABSI rate. The initiation of discussion around this project led to an immediate decline in DUR via increased awareness and focus. As interventions were introduced and implemented, the DUR continued to decrease at a steady rate. Post implementation, the DUR met the project goal of less than 40%. The team continued to track progress and monitor feedback. The DUR continued to meet the goal for three months post implementation. Since the start of the project, there have been no CLABSI events reported. This effort has positively impacted safety and patient outcomes. Conclusions Through a defined process, the central line utilization rate in our ICU was decreased to 37.5% to meet the target goal and has been sustained.

A Case of Herpes Simplex Virus Meningitis in an Immunocompromised Individual: Avoiding Common Diagnostic Pitfalls.

Herpes simplex virus meningoencephalitis (HSV ME) is a severe viral infection that affects the brain and surrounding tissues. It is caused primarily by HSV type 1 (HSV-1) virus. This condition requires prompt recognition and treatment due to its potential for significant morbidity and mortality. We aim to highlight the importance of avoiding common diagnostic pitfalls in identifying HSV meningoencephalitis, especially in immunocompromised individuals. We present a case of a 34-year-old immunocompromised patient with HSV meningoencephalitis, emphasizing key clinical features and diagnostic strategies that helped us reach an accurate diagnosis. By sharing this case, we aim to enhance awareness and improve the management of HSV meningoencephalitis in similar patient populations, leading to better outcomes.

Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is the result of transmural ischemia of the myocardium and is associated with a high mortality rate. Primary percutaneous coronary intervention (PPCI) is the recommended first-line treatment strategy for patients with STEMI. The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019 (COVID-19) pandemic, leading to a projected steep rise in mortality. These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion. It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints. AIM: To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes. METHODS: PubMed, Google Scholar, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic. Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality. Data were meta-analyzed using the random effects model to derive odds ratios (OR) and 95% confidence intervals. Quality assessment was carried out using the Newcastle-Ottawa scale. RESULTS: Fourteen studies including 50136 STEMI patients (n = 15142 in the pandemic arm; n = 34994 in the pre-pandemic arm) were included. The mean age was 61 years; 79% were male, 27% had type 2 diabetes, and 47% were smokers. Compared with the pre-pandemic period, there was a significantly increased overall incidence of fibrinolysis during the pandemic period [OR: 1.80 (1.18 to 2.75); I2= 78%; P = 0.00; GRADE: Very low]. The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting. The countries with a low-and middle-income status reported a higher incidence of fibrinolysis [OR: 5.16 (2.18 to 12.22); I2 = 81%; P = 0.00; GRADE: Very low] and an increased risk of all-cause mortality in STEMI patients [OR: 1.16 (1.03 to 1.30); I2 = 0%; P = 0.01; GRADE: Very low]. Meta-regression analysis showed a positive correlation of hyperlipidemia (P = 0.001) and hypertension (P < 0.001) with all-cause mortality. CONCLUSION: There is an increased incidence of fibrinolysis during the pandemic period, but it has no effect on the risk of all-cause mortality. The low- and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.

Case Report of Acute Q Fever with Hepatitis Progressing to Chronic Q Fever with Endocarditis.

A 35-year-old male greenhouse worker presented with myalgia, fatigue, and fever. Initially, he was thought to have an unspecified viral infection and was treated with conservative therapy. However, the patient's symptoms persisted, and he reported additional symptoms of mild abdominal pain and headaches. Laboratory evaluation was significant for elevated liver enzymes. Due to concern for acute hepatitis and persistent fever the patient was hospitalized. During his hospital course, no infectious etiology was found to explain his symptoms. After discharge from the hospital, additional testing showed positive serology for Q fever IgG phase II antibody (1:8192) and phase II antibody IgM (>1:2048). He was treated with doxycycline and had a good clinical response. Upon follow-up, he had worsening Phase I IgG serologies. Transesophageal echo demonstrated vegetations consistent with endocarditis.

Coronary Artery Dissection and Myocarditis Caused by Eosinophilic Granulomatosis with Polyangiitis (EGPA): A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) also referred to as Churg-Strauss syndrome is a rare vasculitis of the small to medium vessels. We present a rare case of acute coronary artery dissection brought on by EGPA, which generally has a poor prognosis. A 41-year-old male with history of bronchial asthma presented to the emergency room with a 2-week history of dyspnea, cough with clear phlegm, and fever. For the past eight months he had experienced episodes with similar symptoms relieved by steroids. CT chest showed bilateral upper lobe patchy opacities with extensive workup for infectious etiology being negative. He had peripheral eosinophilia with sinusitis. He had acute coronary syndrome and Coronary angiogram showed Right coronary artery dissection. After making a diagnosis of EGPA based on American college of Rheumatology criteria, he was successfully treated with high dose immunosuppression. Coronary artery dissection is a fatal and uncommon complication of EGPA which is usually diagnosed postmortem. Early recognition of this condition ante mortem and aggressive treatment can be lifesaving as demonstrated in our case.

Association of plasma volume status with outcomes in hospitalized Covid-19 ARDS patients: A retrospective multicenter observational study.

PURPOSE: To evaluate the association of estimated plasma volume (ePV) and plasma volume status (PVS) on admission with the outcomes in COVID-19-related acute respiratory distress syndrome (ARDS) patients. MATERIALS AND METHODS: We performed a retrospective multi-center study on COVID-19-related ARDS patients who were admitted to the Mayo Clinic Enterprise health system. Plasma volume was calculated using the formulae for ePV and PVS, and these variables were analyzed for correlation with patient outcomes. RESULTS: Our analysis included 1298 patients with sequential organ failure assessment (SOFA) respiratory score ≥ 2 (PaO2/FIO2 ≤300 mmHg) and a mortality rate of 25.96%. A Cox proportional multivariate analysis showed PVS but not ePV as an independent correlation with 90-day mortality after adjusting for the covariates (HR: 1.015, 95% CI: 1.005-1.025, p = 0.002 and HR 1.054, 95% CI 0.958-1.159, p = 0.278 respectively). CONCLUSION: A lower PVS on admission correlated with a greater chance of survival in COVID-19-related ARDS patients. The role of PVS in guiding fluid management should be investigated in future prospective studies.

Is There a Bias Toward Unvaccinated COVID-19 Patients?

Description With more than 22% of the United States still not vaccinated for COVID-19, we are trying to shed some light on whether there is any bias when treating unvaccinated COVID-19 patients. We highlight several reports where some individuals or organizations displayed possible bias, whether implicit or explicit. We examine the legal and ethical implications of these biases and offer a general overview of how to tackle them.

Bilateral renal mucormycosis following COVID-19 infection: A therapeutic challenge.

India witnessed an epidemic of mucormycosis during the second wave of the COVID-19 pandemic. Renal mucormycosis has been reported rarely, mostly from India, but only 2 cases have been reported following COVID-19 infection to date. We report a case of mucormycosis predominantly affecting kidneys in a young and previously healthy male following COVID-19 pneumonia, for which he had received corticosteroid, remdesivir, and tocilizumab. He presented with hematuria, progressive oliguria, and severe acute kidney injury (AKI) requiring dialysis. The diagnosis was made on kidney biopsy and contrast-enhanced CT (CECT) showed segmental and subsegmental renal artery pseudoaneurysms with distal occlusion of both kidneys. He underwent bilateral nephrectomy and received high-dose amphotericin (AMB) and posaconazole. He developed cardiac arrhythmia and pulmonary edema attributed to AMB-related cardiotoxicity after a cumulative ABM dose of 2,450 mg. This is the first case report describing the survival of a patient with bilateral renal mucormycosis following COVID-19 infection. Our case report highlights the importance of considering mucormycosis in a patient with post-COVID-19 AKI to make an early diagnosis and aggressive management comprising of surgical debridement and high-dose AMB to improve survival.