Case Report: Salmonella typhi Iliopsoas Abscess with Concomitant Sacroiliitis in a Young Immunocompetent Male: A Rare Case.

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.

Clinical characteristics and outcomes in pseudomonas endocarditis: a systematic review of individual cases : Systematic review of pseudomonas endocarditis.

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.

Enteric Fever-Associated Hemophagocytic Lymphohistiocytosis: A Systematic Review of Clinical Characteristics and Outcomes.

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.

Monocrotophos-Induced Intermediate Syndrome Complicated by Hyperammonemic Encephalopathy: A Case Report.

Organophosphorus (OP) poisoning is the most common type of poisoning in India. Amongst the OP, monocrotophos poisoning has the highest lethality and need for mechanical ventilation. Monocrotophos is also implicated in causing OP-induced intermediate syndrome, the prevalence of which is 10-40% of all OP poisoning. The other neurological manifestations are delayed neuropathy and neuropsychiatric syndrome. We herein discuss a case of a 58-year-old male who presented with monocrotophos poisoning and intermediate syndrome. During the hospitalisation course, the patient developed hyperammonemic encephalopathy, resulting in difficulty in weaning from mechanical ventilation. After ruling out all possible causes of hyperammonemia, it was attributed to monocrotophos poisoning. The patient improved significantly after initiating lactulose and was successfully weaned off from the ventilator. This report highlights the high index of suspicion of hyperammonemic encephalopathy in monocrotophos toxicity, which can be easily missed due to other commoner neurological manifestations of organophosphorus poisoning.

The emergence of multidrug-resistant Gram-positive bloodstream infections in India - a single center prospective cohort study.

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.

Epidemiology, clinical presentation, and predictors of outcome in nontuberculous mycobacterial central nervous system infection: a systematic review.

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.

The epidemiology, clinical presentation and treatment outcomes in CNS actinomycosis: a systematic review of reported cases.

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.

Difficult-to-treat resistant gram-negative blood stream infections - the beginning of a superbug era - a prospective observational study.

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.

Invasive cerebral aspergillosis in non-neutropenic patients: A case series from Western India.

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.

Prosthetic valve endocarditis due to Candida parapsilosis - a rare case report.

Fungal endocarditis is a rare and fatal condition, most frequently caused by species of the genera Candida and Aspergillus. Fever and changing heart murmur are the most common clinical manifestations. The diagnosis of fungal endocarditis is challenging, with prosthetic valve endocarditis being extremely difficult to diagnose. The optimal management of the condition still remains debatable. We present a case of prosthetic valve endocarditis caused by Candida parapsilosis, managed empirically with liposomal amphotericin B, which was later shifted to combination therapy with high-dose echinocandin and fluconazole, but had a fatal outcome because the patient could not undergo timely surgical intervention. Treating C. parapsilosis endocarditis cases is difficult because of their biofilm production on native and prosthetic heart valves. A combined approach consisting of a high index of clinical suspicion, early diagnosis using serological markers followed by culture or PCR and prompt initiation of appropriate antifungals may aid in improving outcomes.

Combination therapy in Mucormycosis: Current evidence from the world literature, a mini review.

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.

The evaluation of serum lipid profile in chronic Hepatitis B patients at a Tertiary Care Centre in Western India: A cross-sectional study.

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.

Résumé Introduction: Le virus de l'hépatite B (VHB) est connu comme un métabolovirus en raison de son impact sur le métabolisme des lipides et du glucose dans le foie. Précédent la littérature a montré une tendance à l'hypolipidémie et à une réduction du risque de syndrome métabolique chez les patients positifs à l'antigène de surface de l'hépatite B. Cependant, les données de la population indienne font défaut. Nous évaluons la relation entre le profil lipidique et l'infection par le VHB et la gravité de la maladie hépatique. Matériels et méthodes: Il s'agissait d'une étude transversale observationnelle dans laquelle 50 patients atteints d'hépatite B chronique et 43 des témoins séronégatifs appariés ont été recrutés. Données démographiques, cliniques et de laboratoire, y compris le profil lipidique (lipoprotéines de haute densité [HDL], lipoprotéines de basse densité [LDL], triglycérides et cholestérol total [TC]) ont été collectés. Les patients séropositifs ont été classés en fonction de modèles pronostiques (modèle pour l'hépatopathie terminale [MELD] et score de Child-Pugh) pour une analyse plus approfondie. Résultats: Notre étude a révélé des taux sériques bas significatifs de cholestérol TC, HDL et LDL chez les patients atteints d'hépatite B par rapport aux témoins séronégatifs (133,06 contre 162,39, 35,56 vs 43,65 et 76,62 vs 99,95 mg/dl respectivement, P < 0,05). Les patients avec un MELD et un score de Child-Pugh élevés étaient associés à hypolipidémie. Des niveaux significativement faibles de LDL et de TC ont été observés dans la classe C de Child-Pugh par rapport à la classe A (94,8 vs. 149,2 et 50,6 vs 87,9 mg/dl respectivement, P < 0,05). Conclusions: Une réduction significative de divers paramètres lipidiques a été observée avec l'hépatite chronique B. De plus, le score pronostique (MELD élevé et score de Child-Pugh) était associé à une hypolipidémie. Mots-clés: Cholestérol, maladie hépatique chronique, hépatite B, hypolipidémie, métabolisme lipidique.

Comparison of clinical characteristics and outcome in RT-PCR positive and false-negative RT-PCR for COVID-19: A Retrospective analysis.

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.

Clinical Characteristics and Treatment Outcome of Central Nervous System Nocardiosis: A Systematic Review of Reported Cases.

BACKGROUND: The clinical spectrum of systemic nocardiosis encompasses pulmonary and disseminated disease. Central nervous system (CNS) involvement is an important feature of disseminated disease with significant mortality and high relapse rate, especially in those with suppressed cell-mediated immunity. This systematic review aimed to evaluate the epidemiology, clinical features, diagnosis, therapeutic interventions, and outcome in patients with CNS nocardiosis. METHODS: A literature search was performed in major databases (PubMed, Google Scholar, and Scopus) by using distinct keywords: "CNS disease," "Nocardia," "meningitis," "brain abscess," "disseminated disease," and "Cotrimoxazole." We included all patients ≥18 years with CNS nocardiosis reported between January 2000 and December 2020. RESULTS: A total of 129 papers were included in the final analysis. The mean age of patients was 55 ± 16 years, and the majority were male (70.8%). Nocardia farcinica was the commonest species (39.6%), followed by Nocardia nova (5.9%). Thirty-four percent of the patients were found to be immunocompetent. Corticosteroid use was the most common predisposing factor (55.8%). Among neuroimaging findings, brain abscess was most common (86.9%), followed by leptomeningeal enhancement (12.1%). The overall case-fatality rate in CNS disease was 22.8%. On multivariate analysis, patients who underwent surgery (OR 2.4, 95% CI 0.99-4.11, p value 0.046) had better survival than those treated with antimicrobial therapy alone. Immunodeficient state (OR 0.32, 95% CI 0.15-0.90, p value 0.019) was independently associated with poor outcome. CONCLUSION: CNS nocardiosis carries significant mortality, especially in immunodeficient patients. We advocate the use of surgery combined with antimicrobials to improve clinical outcome.

Progressive disseminated histoplasmosis in idiopathic CD4 lymphocytopenia an underdiagnosed combination - a case report.

Progressive disseminated histoplasmosis (PDH) usually presents as fever, anemia, leukopenia, hepatosplenomegaly, lymphadenopathy and pulmonary symptoms. There are few reports on the association of idiopathic CD4 lymphocytopenia (ICL) with histoplasmosis. We describe a 65-year-old female presented with a history of fever, papulo-nodular rash and significant weight loss and diagnosed as progressive disseminated histoplasmosis. All immunocompromised conditions were ruled out. In addition, her 2 consecutive CD4 counts were below 300. The patient was diagnosed with PDH associated with ICL. The patient showed significant improvement with liposomal amphotericin B and itraconazole. Absolute CD4 counts should be done in all cases of progressive disseminated histoplasmosis even in HIV negative individuals to rule out associated ICL.

Severe Autoimmune Hemolytic Anemia Complicating Treatment-naive Chronic Hepatitis C Infection: A Case Report.

BACKGROUND: Haematological manifestations in Hepatitis C virus (HCV) infection has been uncommon since the advent of direct-acting antiviral drugs (DAAs). However, primary HCV disease can cause significant haematological disease in the form of various autoimmune cytopenias. CASE PRESENTATION: We herein discuss a 68-years-old female with chronic HCV infection for the last 15 years (not on the treatment), presented with complaints of progressive fatigue, exertional dyspnea, and increased abdominal distention over the previous 20 days. Coombs-positive autoimmune haemolytic anaemia (AIHA) was diagnosed based on the haematological evaluation (raised lactate dehydrogenase, indirect bilirubinemia, raised reticulocyte count and direct Coombs positive). The patient showed significant improvement in haematological indices with oral prednisolone. However, she eventually succumbed to her illness due to underlying decompensated liver disease. HCV infection may associate with global derangement of the immune system, which is likely to cause AIHA. Diagnosis of autoimmune cytopenias can be easily missed in HCV positive patients due to underlying decompensated liver disease and portal hypertension. CONCLUSION: Thus, screening of HCV infection is imperative in every patient of AIHA, especially with the high worldwide prevalence of HCV.

Acute Lung Injury with Amphotericin Infusion in a Patient with Invasive Mucormycosis.

BACKGROUND: Amphotericin B is a pivotal drug for the management of invasive fungal infections. However, it has a significant toxicity profile with acute infusion reactions like fever, chills, vomiting, anaphylaxis, and nephrotoxicity in patients with long-term use. Pulmonary reactions mimicking acute pulmonary edema are unusual with amphotericin. CASE DESCRIPTION: We report a case of a 51-year-old male diagnosed with rhinomaxillary mucormycosis, who developed acute onset breathlessness, bilateral diffuse pulmonary infiltrates after amphotericin infusion. The patient recovered spontaneously within a few hours after the cessation of amphotericin, which was parallel with the normalization of Chest X-ray. Furthermore, the Naranjo adverse reaction probability score was 9, which established a definite causal relation between drug use and adverse event. CONCLUSION: Clinicians should be aware of acute lung injury in patients treated with amphotericin infusion. In cases with no alternative available, a slow infusion of amphotericin with close monitoring is required to prevent life-threatening pulmonary reactions.

A Case of Toxoplasma gondii and Strongyloides stercoralis Coinfection in an Immunocompromised Patient.

BACKGROUND: In India, around 23.49 lac people have HIV/AIDS (PLHA). Strongyloidiasis and toxoplasmosis are some of the opportunistic infections that occur in HIV patients, but their dual coinfection with HIV is rarely reported. CASE PRESENTATION: A 46-year-old male was admitted to the hospital with generalized weakness, loss of weight, and bleeding per rectum for the last 3 months and a few episodes of dizziness and fever. RESULTS: On routine investigation, he was diagnosed with human immunodeficiency virus (HIV) infection. On further evaluation, Toxoplasma gondii and Strongyloides stercoralis coinfection, as assessed by the parasitological diagnosis of the serum sample, was positive. Patient was started on artesunate, ART regimen (Tab, TLD- Dolutegravir 50 + Lamivudine 300 + Tenofovir DF 300) and cotrimoxazole. CONCLUSION: Herein, we report a case of Toxoplasma gondii and Strongyloides stercoralis coinfection in an immunocompromised patient.

Isolated Bilateral Abducens Palsy as a Presenting Feature of Multi-Infarct State: A Case Report.

Isolated abducens palsy is a rare clinical entity. The usual causes of bilateral sixth nerve palsy are head trauma, tumor (skull base), aneurysm, and ischemic stroke. Bilateral abducens palsy without any other neurological deficit secondary to ischemic stroke is a rare clinical presentation. We present a case of a 78-year-old male without any comorbidities with a history of diplopia for the last two months. Physical examination was unremarkable except for bilateral sixth nerve palsy. MRI brain showed the chronic ischemic area in the pons, bilateral basal ganglia, deep white matter, and periventricular region of bilateral frontal, temporal, parietal, and occipital lobe. This report highlights an unusual presentation of ischemic stroke as isolated bilateral abducens palsy without any other focal neurological deficit.

Acute Myocardial Infarction in Hemophilia A with HIV and Hyperhomocysteinemia- a rare case report.

BACKGROUND: Patients with hemophilia have a hypocoagulable state and less chances of thrombus formation. Therefore, expected to have a lower cardiovascular mortality than the general population. The lower cardiovascular mortality can be explained by less chances of thrombus formation due to hypocoagulability. CASE PRESENTATION: Here we present a case of a 42-year-old male patient presented with severe chest pain radiating to back for 4 days. ECG was suggestive of recent acute anteroseptal myocardial infarction. There was a history of receiving intravenous recombinant factor VIII, 1 hour prior to the onset of chest pain for knee joint swelling. The occurrence of acute coronary syndromes in patients with hemophilia A is uncommon and rarely reported. CONCLUSION: Here we report a patient of severe hemophilia A who developed acute myocardial infarction after administration of recombinant factor VIII.