Prevalence of co-existent COVID-19-associated pulmonary aspergillosis (CAPA) and its impact on early mortality in patients with COVID-19-associated pulmonary mucormycosis (CAPM).

BACKGROUND: Data on mixed mould infection with COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated pulmonary mucormycosis (CAPM) are sparse. OBJECTIVES: To ascertain the prevalence of co-existent CAPA in CAPM (mixed mould infection) and whether mixed mould infection is associated with early mortality (≤7 days of diagnosis). METHODS: We retrospectively analysed the data collected from 25 centres across India on COVID-19-associated mucormycosis. We included only CAPM and excluded subjects with disseminated or rhino-orbital mucormycosis. We defined co-existent CAPA if a respiratory specimen showed septate hyphae on smear, histopathology or culture grew Aspergillus spp. We also compare the demography, predisposing factors, severity of COVID-19, and management of CAPM patients with and without CAPA. Using a case-control design, we assess whether mixed mould infection (primary exposure) were associated with early mortality in CAPM. RESULTS: We included 105 patients with CAPM. The prevalence of mixed mould infection was 20% (21/105). Patients with mixed mould infection experienced early mortality (9/21 [42.9%] vs. 15/84 [17.9%]; p = 0.02) and poorer survival at 6 weeks (7/21 [33.3] vs. 46/77 [59.7%]; p = 0.03) than CAPM alone. On imaging, consolidation was more commonly encountered with mixed mould infections than CAPM. Co-existent CAPA (odds ratio [95% confidence interval], 19.1 [2.62-139.1]) was independently associated with early mortality in CAPM after adjusting for hypoxemia during COVID-19 and other factors. CONCLUSION: Coinfection of CAPA and CAPM was not uncommon in our CAPM patients and portends a worse prognosis. Prospective studies from different countries are required to know the impact of mixed mould infection.

Risk factors, mortality, and predictors of survival in COVID-19-associated pulmonary mucormycosis: a multicentre retrospective study from India.

OBJECTIVES: To compare COVID-19-associated pulmonary mucormycosis (CAPM) with COVID-19-associated rhino-orbital mucormycosis (CAROM), ascertain factors associated with CAPM among patients with COVID-19, and identify factors associated with 12-week mortality in CAPM. METHODS: We performed a retrospective multicentre cohort study. All study participants had COVID-19. We enrolled CAPM, CAROM, and COVID-19 subjects without mucormycosis (controls; age-matched). We collected information on demography, predisposing factors, and details of COVID-19 illness. Univariable analysis was used to compare CAPM and CAROM. We used multivariable logistic regression to evaluate factors associated with CAPM (with hypoxemia during COVID-19 as the primary exposure) and at 12-week mortality. RESULTS: We included 1724 cases (CAPM [n = 122], CAROM [n = 1602]) and 3911 controls. Male sex, renal transplantation, multimorbidity, neutrophil-lymphocyte ratio, intensive care admission, and cumulative glucocorticoid dose for COVID-19 were significantly higher in CAPM than in CAROM. On multivariable analysis, COVID-19-related hypoxemia (aOR, 2.384; 95% CI, 1.209-4.700), male sex, rural residence, diabetes mellitus, serum C-reactive protein, glucocorticoid, and zinc use during COVID-19 were independently associated with CAPM. CAPM reported a higher 12-week mortality than CAROM (56 of the 107 [52.3%] vs. 413 of the 1356 [30.5%]; p = 0.0001). Hypoxemia during COVID-19 (aOR [95% CI], 3.70 [1.34-10.25]) and Aspergillus co-infection (aOR [95% CI], 5.40 [1.23-23.64]) were independently associated with mortality in CAPM, whereas surgery was associated with better survival. DISCUSSION: CAPM is a distinct entity with a higher mortality than CAROM. Hypoxemia during COVID-19 illness is associated with CAPM. COVID-19 hypoxemia and Aspergillus co-infection were associated with higher mortality in CAPM.

Dengue and Other Viral Hemorrhagic Fevers.

How to cite this article: Shastri PS, Taneja S. Dengue and Other Viral Hemorrhagic Fevers. Indian J Crit Care Med 2021;25(Suppl 2):S130-S133.

Multicenter Epidemiologic Study of Coronavirus Disease-Associated Mucormycosis, India.

During September-December 2020, we conducted a multicenter retrospective study across India to evaluate epidemiology and outcomes among cases of coronavirus disease (COVID-19)-associated mucormycosis (CAM). Among 287 mucormycosis patients, 187 (65.2%) had CAM; CAM prevalence was 0.27% among hospitalized COVID-19 patients. We noted a 2.1-fold rise in mucormycosis during the study period compared with September-December 2019. Uncontrolled diabetes mellitus was the most common underlying disease among CAM and non-CAM patients. COVID-19 was the only underlying disease in 32.6% of CAM patients. COVID-19-related hypoxemia and improper glucocorticoid use independently were associated with CAM. The mucormycosis case-fatality rate at 12 weeks was 45.7% but was similar for CAM and non-CAM patients. Age, rhino-orbital-cerebral involvement, and intensive care unit admission were associated with increased mortality rates; sequential antifungal drug treatment improved mucormycosis survival. The COVID-19 pandemic has led to increases in mucormycosis in India, partly from inappropriate glucocorticoid use.

A prospective 3 year study of clinical spectrum and outcome of dengue fever in ICU from a tertiary care hospital in North India.

BACKGROUND AND AIMS: The incidence of specific complications and adverse outcomes in dengue patients needing admission to intensive care units (ICU) may be quite variable in different regions of India presumably because of different strains of dengue virus or due to re infection. METHODS: Patients admitted with acute febrile illness (AFI) with either positive IgM antibody or NS1 antigen for dengue were enrolled. Data were collected for 3 years (2015-2017). A total of 313 patients with acute febrile illness were admitted in the study period (2252 total ICU admissions). A total of 137 (43.76%) cases were serologically proven as dengue fever. RESULTS: Median age (IQR) of study population was 36.0 (26.0-52.0) years. Liver (65.7%) was the main organ involved followed by acute kidney Injury (AKI) (18.6%). Dengue Shock Syndrome (DSS) was found in 18.6% of cases. Fifty-two patients died and the crude mortality was 38.0%. On multivariate analysis APACHE Score <10, thrombocytopenia, hepatic dysfunction, AKI and dengue shock syndrome (DSS) were associated with the risk of mortality. CONCLUSION: This study in ICU patients showed high mortality in relatively younger patients. Liver (in the form of raised Bilirubin) was the most common organ dysfunction. The need to recognise early warning signs for ICU admission is highlighted.

Candida auris candidaemia in an intensive care unit - Prospective observational study to evaluate epidemiology, risk factors, and outcome.

PURPOSE: To determine the prevalence of Candida auris candidaemia in our ICU patients and its molecular epidemiology. METHODS: A prospective observational study was conducted on candidaemia in our ICU patients over 18 months during 2016-2017. Demographics, underlying disease, risk factors, antifungal therapy and outcome were studied. Risk factors of C. auris and non-auris candidaemia were compared. RESULTS: During the study period, among 108 candidaemia cases recorded, the incidence was 6.75/1000 ICU bed days. C. auris topped the list (n = 42, 39.9%), followed by C. tropicalis (34.3%), and C. parapsilosis (15.7%). On bivariate analysis prior antibiotic therapy, long central line days, mechanical ventilation and length of ICU stay were significant risk factors for C. auris candidaemia compared to non-auris candidaemia. Multivariate analysis showed underlying respiratory and neurological diseases as significantly associated with risk of C. auris candidaemia. Fluconazole, amphotericin B, and caspofungin resistance were noted in 97.0%, 93.7% and 3% of C. auris isolates respectively. CONCLUSION: Longer duration of central line days, prior antibiotic use, mechanical ventilation and prolonged ICU stay were important risk factors associated with C. auris candidaemia along with underlying respiratory or neurological disease. The isolates are non-clonal in origin, but they belong to a single clade.

Fulminant Histoplasmosis Presenting as Pyrexia of Unknown Origin in Immunocompetent Adult Diabetic Patient.

Opportunistic infections are commonly seen in immunocompromised individuals such as those suffering from HIV infection, organ transplant recipients and connective tissue disorders. Histoplasmosis is one of the fungal opportunistic infections which is usually seen in immunosuppressed individuals but can also be seen in immunocompetent patients with frequent involvement of adrenal glands. We present a case of adult diabetic patient presenting as pyrexia of unknown origin in which bone marrow aspiration and biopsy lead to diagnosis of histoplasmosis without adrenal involvement. How to cite this article: Shastri P, Gupta P. Fulminant Histoplasmosis Presenting as Pyrexia of Unknown Origin in Immunocompetent Adult Diabetic Patient. Indian J Crit Care Med 2019;23(4):193-195.