Case Report and Review of the Literature: Ischemic Stroke in Dengue Virus Infection.

Dengue continues to pose a global health challenge, particularly in tropical and subtropical areas. Dengue can impact various organs, including the central nervous system, and can cause various neurological symptoms, although stroke is an uncommon complication. Among strokes, ischemic stroke is very uncommon in dengue. A 27-year-old unmarried female was referred to our institution with 8 days of fever and myalgia, 5 days of vomiting, and 3 days of altered sensorium. Small-sized bilateral pupils reacted slowly to light. Chest auscultation revealed diffuse coarse crepitation. Poor general condition and labored breathing led to intensive care unit transfer and intubation. Her contrast-enhanced brain magnetic resonance image showed chronic pontine infarction. She was diagnosed with dengue fever (NS1Ag positive) complicated by bilateral pontine infarction. After a long course of illness, she was finally discharged to home in good recovery status. Clinicians need to be aware of the uncommon dengue presentation of stroke. Treatment is supportive with variable outcomes.

Amphotericin B Deoxycholate Treatment of Post-Kala-Azar Dermal Leishmaniasis in India.

Post-kala-azar dermal leishmaniasis (PKDL) is widely prevalent in the endemic regions of India, but its treatment remains unsatisfactory. The WHO recommends a 12-week treatment with oral miltefosine, but its ocular toxicities are a serious concern. The late 1980s and early 1990s saw the use of sodium stibogluconate and amphotericin B (AmB) for a brief period. Both drugs had frequent adverse events and were expensive, and the duration of treatments was unacceptably long. This retrospective study evaluated, analyzed, and reported the outcomes of PKDL patients treated with a shorter course of AmB, the most effective antileishmanial drug. The hospital records of PKDL patients treated with AmB by 30 alternate-day infusions over 60 days (instead of conventional 60-80 infusions over 100-120 days) between September 2010 and August 2016 were reviewed. Only patients with confirmed parasitological diagnosis were included. Their records were studied for treatment-related adverse events, end-of-treatment parasitological status, and 12-month follow-up results. One hundred two patients were eligible for this study between September 2010 and August 2016. After therapy, 92/102 (90.2%) patients improved; 3 (2.9%) had to cease treatment owing to severe adverse effects, and one died of severe diarrhea unrelated to AmB. Six (5.9%) patients withdrew consent before the treatment was complete. At the 12-month evaluation, 89/102 (87.3%) patients attained a final cure. A 30-infusion regimen of AmB remains highly effective in PKDL. Without a shorter, safer, and more economical regimen for the treatment of PKDL, it should be used until a better regimen is available.

Digital Gangrene Associated with Scrub Typhus: A Case Series.

Rickettsial diseases cover a broad spectrum of illnesses. Scrub typhus is present worldwide, and Orientia tsutsugamushi is the causative agent of this chigger mite-borne infectious illness. Infections exhibit a range of severity, from mild illness to the more severe manifestation of multiorgan failure. We report three cases of scrub fever (55-year-old female, 63-year-old female, and 29-year-old male), all cases developed focal or pan-digital gangrene. All cases were successfully treated by administering doxycycline and additional supportive measures. Digital gangrene is uncommon in scrub typhus. Clinical suspension for early diagnosis and appropriate treatment may avoid further complications.

Leptospirosis Associated Digital Gangrene of Lower Extremities: Two Cases and Review of Literature.

BACKGROUND: Leptospirosis is the most common zoonotic illness worldwide, caused by pathogenic spirochete bacteria called Leptospirosis. It is clinically presented with mild to moderate in most cases. However, sometimes, the course may be severe with multiorgan dysfunction. CASE PRESENTATION: We present two rare cases of Leptospirosis with peripheral dry gangrene of the lower extremities. A 25-year-old male, farmer by occupation without any significant past medical history had been diagnosed with a case of Leptospirosis that complicated to digital gangrene on 15 days of illness during hospitalization. Another 21-year-old male student was admitted for leptospirosis and developed digital gangrene on 19 days of illness. All clinical findings were resolved on the steroid. CONCLUSION: Apart from a high index of suspicion and awareness of unusual manifestations, serology plays a vital role in making an accurate and quick diagnosis to initiate appropriate therapy.

Spontaneous Intracranial Hemorrhage and Acute Respiratory Distress Syndrome Associated with Dengue: A Case Report.

BACKGROUND: Dengue is a major health burden worldwide, notably in tropical and subtropical countries, with symptoms ranging from asymptomatic infection to severe hemorrhagic or shock syndrome. The clinical and biochemical profile of dengue has been shown in the literature to be expanding as more atypical signs have been added over the past few decades. Most dengue-related symptoms are typically mild to moderate and self-limited. However, intracranial hemorrhage and acute respiratory distress syndrome in severe dengue is an event that has been encountered uncommonly. CASE PRESENTATION: A 30-year-old female presented with complaints of fever, headache, cough, and altered sensorium. Later, she was diagnosed with severe dengue fever complicated by dengue hemorrhagic fever, which manifested as subarachnoid and subdural bleeding and acute respiratory distress syndrome. She was managed conservatively with a positive outcome. CONCLUSION: Atypical manifestation, though rare, should be kept in mind while dealing with severe dengue patients, as early detection based on anticipated risk factors and timely treatment have the potential to save lives.

Impact of secondary infections on dengue presentation: A cross-sectional study in a tertiary care hospital in Uttar Pradesh, India.

BACKGROUND: Recently, a wide range variety of manifestations, including a self­limiting to severe illness, has been increasingly reported in dengue. Few studies attract attention to severe dengue, mainly observed in secondary infection. With this background, this study aims to provide a comprehensive overview to differentiate primary from secondary dengue using serology (IgG) and the possible association of severity of illness in secondary dengue. METHODS: Present retrospective cross-sectional study was conducted at a North Indian tertiary care center from September 2021 to January 2022. Clinical data of confirmed dengue patients from the medicine department were collected and assigned as primary and secondary dengue. RESULTS: Of the 220 dengue patients, 22 (10 %) had secondary dengue infection. Hemorrhagic manifestations were reported in 58/220 (26.4 %) cases while 7/22 (31.8 %) in secondary dengue. Prevalent hemorrhagic manifestations in secondary dengue include purpura (27.3 %), vaginal bleeding (4.5 %), melaena (9.1 %), and epistaxis (4.5 %). In addition, 42 (19.1 %) patients had pancytopenia, and 8 (36.6 %) cases were of secondary dengue. Hepatic dysfunction was noted in 164 (74.5 %) cases. Notably, all secondary dengue cases (22;100 %) had hepatic dysfunction and severe in 9 (40.9 %) cases. In addition, in secondary dengue patients, evidence of plasma leakages such as hypoproteinemia 7 (31.8 %) and ascites (35 %) were statistically more frequent. Overall, two deaths (0.9 %) were reported, and were one in each group. CONCLUSIONS: Many parameters, including hemorrhagic manifestation (melaena), hematological characteristic (pancytopenia), evidence of plasma leakage (hypoproteinemia and ascites), gastrointestinal (GB wall thickening and hepatic dysfunction) and reduction in mean hemoglobin and platelet count were found to be statistically significant in secondary dengue infection. Additionally, early classification of secondary dengue may help to anticipate its severity and allow for early strategic intervention/management to lower morbidity and mortality.

Massive Splenomegaly with Pancytopenia in an Adult: Gaucher's Disease.

INTRODUCTION: Gaucher's disease (GD) is a rare lysosomal storage disease. It is characterized by the deposition of glucocerebroside in cells of the macrophage-monocyte system. GD presents a broad clinical expression, including hematologic abnormalities (such as pancytopenia), massive hepatosplenomegaly, diffuse infiltrative pulmonary disease, renal involvement in the form of nephropathy and glomerulonephritis, skeletal involvement in the form of bone pain, bony infarct, osteopenia, and pathological fracture. Based on the presence or absence of neurologic involvement, it is differentiated into type 1, type 2, and type 3. Gaucher's disease type 1 is the most common form, having the nonneuropathic form and carrying autosomal recessive traits. Gaucher's disease affects all racial and ethnic groups, while type 1 GD is most prevalent among Ashkenazi Jews. CASE PRESENTATION: A 20-year-old female was admitted to the medicine department with complaints of generalized weakness and easy fatigability, menorrhagia, and a dragging sensation in the abdomen. On clinical evaluation, she had bone marrow failure syndrome features along with massive splenomegaly. Later, she was confirmed with Gaucher disease type 1 disease by clinical and investigation (low ß-glucosidase level) evaluation. CONCLUSION: This case emphasizes keeping a differential diagnosis of glycogen storage disorder while evaluating a case of unexplained pancytopenia with massive splenomegaly in adulthood for an extended period. Currently, enzyme replacement therapy and substrate reduction therapy are the mainstay therapeutic options for GD.

A strict vegetarian diet may be harmful: bilateral macular bleeding in vitamin B12 deficiency.

A 35-year-old Indian male office worker presented with complaints of progressive weakness, fatigability, and diminished vision. The patient followed a strict vegetarian diet. Clinical examination revealed pallor. Fundoscopy revealed a bilateral macularbleed. Vitamin B12 deficiency was determined to be the cause based on the clinical and laboratory results. Three months later, he reported a near-normal vision in both eyes and a normal complete hemogram. The present clinical picture demonstrates an unusual facet of clinical feature in vitamin B12 deficiency, an event rarely encountered.

Safety and Effectiveness of Miltefosine in Post-Kala-Azar Dermal Leishmaniasis: An Observational Study.

Background: Post-kala-azar dermal leishmaniasis (PKDL) is a dermal complication of visceral leishmaniasis. Oral miltefosine (MF) is the first-line treatment for PKDL patients in South Asia. This study assessed the safety and effectiveness of MF therapy after 12 months of follow-up to explore more precise data. Methods: In this observational study, 300 confirmed PKDL patients were enrolled. MF with the usual dose was administered to all patients for 12 weeks and followed up for 1 year. Clinical evolution was recorded systematically by photographs at screening and at 12 weeks, 6 months, and 12 months after treatment onset. Definitive cure consisted of disappearance of skin lesions with a negative PCR at 12 weeks or with >70% of lesions, disappearing or fading at 12-month follow-up. Patients with reappearing clinical features and any positive diagnostics of PKDL during the follow-up were considered as nonresponsive. Results: Among 300 patients, 286 (95.3%) completed 12 weeks of treatment. The per-protocol cure rate at 12 months was 97%, but 7 patients relapsed and 51 (17%) were lost to 12-month follow-up, resulting in a final cure rate of only 76%. Eye-related adverse events were noted in 11 (3.7%) patients and resolved in most (72.7%) within 12 months. Unfortunately, 3 patients had persistent partial vision loss. Mild to moderate gastrointestinal side effects were seen in 28% patients. Conclusions: Moderate effectiveness of MF was observed in the present study. A significant number of patients developed ocular complications, and thus MF for treatment for PKDL should be suspended and replaced with a safer alternative regimen.

Adenovirus Meningoencephalitis and Neurocysticercosis Co-infection: First Case from India.

BACKGROUND: Adenovirus generally causes upper and lower respiratory tract infections. It is common in children and occasionally in adults. Neurological involvement is rare, which may be mild aseptic meningitis to potentially fatal acute necrotizing encephalopathy. Recently, viruses have been reported increasingly to cause CNS infections. Viral aetiology typically varies with age. CASE PRESENTATION: Here, we report an unusual adenovirus meningoencephalitis with a co-infection of neurocysticercosis in an immunocompetent adult patient. An 18-year-old healthy female student was admitted with fever and headache for 11 days and progressive altered behaviour for 5 days, followed by altered sensorium for 3 days. This variable and unusual presentation of adenoviral infection involving CNS provoked diagnostic difficulties, but with the help of advanced diagnostics, especially molecular, exact aetiology was detected. Even with the neurocysticercosis infection in this patient, the outcome was not adversely affected. CONCLUSION: This unusual co-infection with a successful outcome is the first case of this type in literature.

Recurrent hypokalemic paralysis in hypothyroidism.

Hypothyroidism, a commonly encountered thyroid disorder, usually manifests with readily recognizable typical features. However, an unusual presentation of a classic thyroid disorder may hinder accurate diagnosis in certain instances. One such rare initial presentation of hypothyroidism is recurrent hypokalemic paralysis, and existing reports in the literature are sparse. It has been more commonly reported in thyrotoxicosis. We report the case details and clinical outcomes of two middle-aged individuals (a 34-year-old male and a 37-year-old female) with recurrent episodes of hypokalemic paralysis. Their clinical examination revealed pure motor hyporeflexia quadriparesis with hypotonia and diminished deep tendon reflexes without any autonomic dysfunction. They had no significant previous medical history. Biochemical findings revealed hypokalemia in both cases (1.4 and 1.9 mEq/L, respectively) with elevated levels of thyroid­stimulating hormone and thyroid­related antibodies in both individuals, thus, confirming the diagnosis of autoimmune hypothyroidism. Immediate treatment with intravenous and oral potassium correction helped in the recovery. Thyroxine supplementation was considered a follow-up treatment, and for a one-year follow-up period there were no complaints of limb weakness reported in both individual.

Disseminated Cryptococcosis in Idiopathic CD4+ Lymphocytopenia.

INTRODUCTION: Idiopathic CD4+ Lymphocytopenia (ICL) is a rare entity grouped in non- HIV-related syndromes. ICL is characterized by a marked low CD4 T cell count of <300 cells/mm3 with ambiguous natural history and prognosis. In addition, cryptococcal and nontuberculous mycobacterial infections are reported as known opportunistic infections. Therefore, management turns around vigilant follow-up and treatment of the current clinical scenario of these patients. CASE PRESENTATION: Here, a 55-year-old lady was referred with a history of diffuse headache and intermittent fever for two months, projectile vomiting, and altered mental status for five days. Nonpruritic maculopapular rashes and diffuse desquamation of the skin were noted. She had no significant previous medical history. Based on clinical findings and investigations, she was diagnosed with ICL having disseminated cryptococcosis. Unfortunately, the patient did not undergo specific treatment as she was recognized late, and unfortunately, she died. CONCLUSION: It is of paramount importance to recognize the clinical entity as early as possible to start appropriate treatment, which may positively impact the outcome. Therefore, the clinician must be aware of disseminated cryptococcosis associated with non-HIV states.

Recurrent Nausea and Vomiting with Weight Loss Associated with Hypothyroidism: Fact or Myth.

BACKGROUND: Hypothyroidism is a commonly encountered endocrine disorder presenting in various clinical settings. It usually presents with classic manifestations, which are readily recognized and, therefore, easy to diagnose. However, occasionally, patients present with unusual symptoms, which becomes a challenge to diagnose. Thyroid dysfunction affects many body organs, including the gut and viscera. Studies show that intestinal motility might be affected by multiple factors, such as neuromuscular dysfunction, myopathy, or alterations in hormone receptors. CASE PRESENTATION: Here, we present the first case of a 21-year-old female student who had complaints of recurrent nausea, vomiting, loose stool, abdominal pain, and weight loss. In the second case, a 25-year-old male student presented with recurrent nausea, vomiting, loose stool, and weight loss. Their unremarkable blood routines and gastrointestinal-specific investigations failed to ascertain the diagnosis. Later, primary hypothyroidism was established by typical biochemical abnormalities. CONCLUSION: Thyroxine replacement treatment successfully resolved the presenting symptoms and normalized biochemical reports.

COVID-19 Associated Pancytopenia (CAP): A Clinical Impact.

BACKGROUND: SARS-CoV-2 infection has mild and asymptomatic to critical clinical course affecting mainly the lungs. Few case reports of COVID-19-associated pancytopenia are reported, but a series of 18 cases is not described in the literature to date. AIMS AND OBJECTIVES: This study aimed to investigate pancytopenia in COVID-19 and its correlation with severity and to explore the detailed clinical and biochemical information in COVID-19- associated pancytopenia. This study also highlights pancytopenia's rarity and prognostic value among COVID-19 patients. MATERIALS AND METHODS: This was a retrospective observational study conducted in a tertiary care centre at a level 3 COVID care facility that included adults of either sex having positive RT PCR for COVID-19 from October 2020 to May 2021. Data were collected from the online outpatient department and hospitalized patients. RESULTS: A total of 18 cases were included in the study; 13 were males (72.2%). The mean age was calculated as 48.56 years. Cases were categorized as severe 13 (72.2%) and non-severe 5 (27.8%) disease on the first day of pancytopenia. The most common presentations were fever 18 (100%) and cough 18 (100%), followed by generalized weakness 16 (88.9%), breathlessness 15 (83.3%), and diarrhoea 10 (55.6%). One case died in the severe disease group. The mean of haemoglobin, leukocyte count, and platelets in severe vs non-severe disease were calculated as 8.59 vs 8.74, 2339 vs 2578, and 77769 vs 88600, respectively. CONCLUSION: Pancytopenia was more prevalent in severe disease and age group 40-60 years. CAP was most likely due to secondary bone marrow suppression. It has no prognostic value for disease outcomes.

Disseminated Tuberculosis in an Immunocompetent State: A Case Report.

BACKGROUND: Tuberculosis is one of the major infectious diseases of mankind and remains a significant health concern, especially in developing countries. Clinical manifestations of TB are broad and sometimes very challenging for clinicians to diagnose early. Tuberculous psoas abscess was generally secondary to spinal tuberculosis or direct extension from adjacent structures in immunocompromised individuals, but tuberculous psoas abscess in the immunocompetent state is very infrequent. In addition, pancytopenia and new onset neck swelling simultaneously make this presentation a very unusual clinical entity in tuberculosis. CASE PRESENTATION: We now present a case of a 21-years-old, unmarried, otherwise healthy girl presented with fever, lower abdominal pain and weight loss for two months. She also noticed painless neck swelling for 15 days. She later had a tuberculous left sided psoas abscess with pancytopenia and a cold abscess on the left side of the neck with no sign of any other apparent focus, according to the evidence. Diagnosis of disseminated TB without lung involvement was established and ATT was started. The outcome was successful on follow up. CONCLUSION: Among the broad spectrum of atypical manifestations of TB, this case report draws attention to its rarity, diagnostic challenge and awareness of the clinical spectrum, especially in developing countries.

Vitamin B12 deficiency in northern India tertiary care: Prevalence, risk factors and clinical characteristics.

Background: Vitamin B12 deficiency leads to a diversity of symptoms and affects many systems. It is often overlooked or sometimes even misdiagnosed in clinical practice. Aims and Objectives: The purposes of this study were to report the prevalence of vitamin B12 deficiency, the spectrum of clinical features and to draw attention to the possibility of rare hidden characteristics. Materials and Methods: This study was a multicenter, retrospective, and prospective conducted at a tertiary care teaching hospital and multispecialty hospital. All cases of vitamin B12 deficiency of either sex or age attending the Medicine Department were enrolled in this study from Aug 2015 to Dec 2020. Parenteral vitamin B12 was given, and cases were evaluated for the response on follow-up for more than three months. Results: Of 220 cases, 52.27% were males. Maximum cases were reported from the age group 50 to 65 years (27.27%) and belonged to urban areas (59.1%). The majority were strict vegetarian (86.36%). Among comorbidities, diabetes (20.91%) followed by malabsorption (10.45%) were most common. The cutaneous manifestations were revealed at 38.18%. The most frequent neurological manifestation was paraesthesia (98.18%). Head heaviness/ache was the most frequent (95%) psychiatric manifestation. Anemia was revealed in 87.73% of cases with 88.64% macrocytosis. Axonal sensorimotor (52.63%) neuropathy was a prevalent finding of NCV study. Conclusions: A high index of clinical suspicion is needed in cases with vague manifestations, especially in the pure vegetarian population. Early recognition can prevent further damage as most of its related disorders are generally reversible with treatment.

COVID-19 Associated Acute Pancreatitis: A Case Series from India.

INTRODUCTION: Initially, COVID-19 was typically concerned with respiratory symptoms and had a mild and asymptomatic to critical clinical course. Over time, many atypical presentations related to cardiac, hepatic, gastrointestinal, renal, musculoskeletal, and neurological features have been reported in COVID-19. CASE PRESENTATION: We present three confirmed cases of COVID-19, who developed acute pancreatitis without any other obvious discernible cause. One middle-aged 48-years old male was presented with severe abdominal pain with mild symptoms of COVID-19, who was later diagnosed with acute pancreatitis with a positive outcome. Another 40-year-old male, hospitalized due to moderate COVID-19, developed acute pancreatitis and was managed successfully. The third 58-year-old patient with control diabetes and severe COVID-19 developed acute necrotizing pancreatitis. Unfortunately, he succumbed due to multiorgan failure while on the mechanical ventilator. CONCLUSION: Acute pancreatitis is uncommon in COVID-19. Although, it should be kept as a highindex clinical suspicion if abdominal pain is reported. Early diagnosis and prompt management can significantly impact the patient's outcome.

Demographic, Clinical, and Investigational Characteristics of COVID-19- related Guillain-Barré Syndrome with Differences from Typical and Another Virus-related Guillain-Barré Syndrome.

BACKGROUNDS: SARS-CoV-2 infection typically presents with fever and respiratory symptoms. Besides this, COVID-19-related central and peripheral nervous system manifestations are emerging. OBJECTIVES: This study summarises the demographics, clinical profiles, laboratory findings, management strategies, and outcomes in a large number of patients with COVID-19-related GBS and its variants. We also compared its clinical profile with Zika and dengue virus-related GBS. METHODS: The authors carried out a literature search up to Dec 31, 2020, in MEDLINE, PubMed, SCOPUS, Cochrane database, and Google Scholar for all published articles. RESULTS: The study identified 54 different types of articles consisting of 70 cases from 17 countries worldwide. A maximum of 15 cases (21.4 %) were identified from Italy, followed by the USA (12; 17.1 %), Spain (11; 15.7 %), and Iran (10; 14.3 %). The age group that was more than 60 years had the most cases, i.e., 32 (45.7 %), followed by the age group 40-60 with 25 cases (35.7 %) with a male to female ratio of 2. Maximum cases were treated with IVIG infusion 58 (82.9 %), followed by Plasma exchange 13 (18.6 %) cases. Out of 70 cases, 7 (10 %) cases were manifested as Miller-Fisher syndrome. The most predominant electrodiagnostic variant was demyelinating neuropathy in 41 (73.21 %) cases. The outcome reported in 67 cases was survival in 63 (90 %) cases and death in 4 (5.7 %) cases. CONCLUSION: Covid-19-related GBS were reported worldwide with a better outcome. Both postinfectious and parainfectious patterns were reported. Early recognition with prompt management of GBS can prevent further severe morbidity and mortality.

Uncommon manifestations in tuberculosis: An expanding clinical spectrum from North India.

Background: Despite being given the best by the health department to eradicate the disease, an alarming rise of tuberculosis (TB) remains a significant public health concern in India. Recently, highly variable clinical manifestations of TB have been reported. This study highlights the unusual presentations of TB with a comprehensive overview of epidemiology, demography and risk factors in the expended clinical spectrum of TB patients and their outcomes. Methods: It is a retrospective study using the records of 503 TB patients of all age groups of either sex from July 2017 to January 2021 at two tertiary care hospitals in North India. Results: Out of 503 cases, pulmonary, extrapulmonary, and disseminated TB were 77.7%, 19.5%, and 2.8%, respectively. Among all TB cases, 36 (7.2%) had uncommon manifestations, including the most common was pyrexia of unknown origin in 12 (33.3%) cases and liver abscess in 5 (13.9%) cases, followed by pancytopenia in 4 (11.1%) cases and chyluria in 3 (8.3%) cases. Atypical skin nodules and multiple swellings were also noted in three (8.3%) cases. Male sex (58%) and rural area (66.7%) were dominant in TB with uncommon manifestation (TBU) cases. The mean age in TBU cases was 46.92 years, whereas 34.26 years in all TB cases. It was extremely significant. The statistically significant risk factors in the TBU case were low socioeconomic status (24, 66.7%), inadequate nutrition (11, 30.6%), and smoking (19, 52.8%). Conclusions: Early recognition of uncommon presentations is imperative to respond better.

Dengue induced reversible blindness.

Dengue is spread by the bite of infected Aedes aegypti mosquito. It is usually a self-limiting viral infection but sometimes complicates to mortality. In the last few decades, literature has shown that clinical and biochemical profile of dengue is expanding due to the addition of unusual manifestation day by day. Hereby, we report a young male student suffering from dengue complicated to retinal hemorrhage and severe pancytopenia who recovered near fully on treatment.