Collapsing Glomerulopathy in a Patient with Tuberculosis and Poncet's Disease.

A 39-year-old woman presented with inflammatory polyarthritis, low-grade fever, progressive pedal edema, and frothy urination of three weeks duration. She had nephrotic range proteinuria and elevated creatinine. Kidney biopsy showed collapse of capillary tuft in the glomeruli and proliferation, hyperplasia, and hypertrophy of the overlying podocytes suggestive of collapsing glomerulopathy. Histology of the cervical lymph node showed necrotizing granulomatous inflammation suggestive of tuberculosis. With all other possible causes of polyarthritis ruled out, a diagnosis of Poncet's disease-a form of polyarthritis observed in patients suffering from an active form of extrapulmonary tuberculosis (TB)-was considered. Association between TB lymphadenitis and collapsing glomerulopathy (CG) is very rare, and the patient had partial remission of the disease after being started on anti-tuberculosis therapy (ATT) along with steroids.

Real-World Effectiveness of COVID-19 Vaccine and Identification of SARS-CoV-2 Variants among People Living with HIV on Highly Active Antiretroviral Therapy in Central Kerala of India-An Ambi-Directional Cohort Study.

BACKGROUND: Vaccine effectiveness for first-generation coronavirus disease (COVID-19) vaccines among People Living with HIV (PLHIV) in India remains unexplored. This study entails the estimation of the real-world effectiveness of COVID-19 vaccines (AZD1222/Covishield, BBV152/Covaxin) among PLHIV and the identification of variants of SARS-CoV-2 among those infected with COVID-19. METHODS: An ambi-directional cohort study was conducted among 925 PLHIV above 18 years of age in two districts of central Kerala, India, from February 2022 to March 2023. Selected PLHIV were recruited as Participant Liaison Officers (PLOs) for the follow-up on the study participants. At enrolment, basic details, baseline CD4 count, and a Nasopharyngeal (NP) swab for RT-PCR were collected. In the follow-up phase, NP swabs were collected from subjects with COVID-19 symptoms. Positive subjects had a CD4 count and genomic sequencing performed. RESULTS: The mean age of the participants was 46.93 ± 11.00 years. The majority, 819 (93.6%), of participants had received at least one dose of any vaccine, while 56 (6.4%) were unvaccinated. A total of 649 (79.24%) participants were vaccinated with Covishield and 169 (20.63%) with Covaxin. In the vaccinated group, 158 (19.3%) reported COVID-19 infection. Vaccine Effectiveness (VE) for one dose of any vaccine was 43.2% (95% CI: 11.8-64.5), p = 0.015. The effectiveness of full vaccination with Covishied was 63.8% (95% CI: 39.3-79.2), p < 0.001, and Covaxin was 73.4% (95% CI: 44.3-87.3). VE was highest, at 60.7% (95% CI: 23.6-81.3), when the two doses of the vaccine were given at an interval of less than 6 weeks. Participants with a baseline CD4 count > 350 had greater protection from COVID-19, at 53.4% (95% CI: 19.6-75.3) p = 0.004. The incident cases were sub-variants of Omicron (BA.2, BA.2.38, BA.2.10). CONCLUSIONS: Full vaccination with Covishield and Covaxin was effective against COVID-19 infection among PLHIV on treatment; albeit, that of Covaxin was higher. A gap of 4 to 6 weeks between the two doses of COVID-19 vaccine was found to have higher VE among PLHIV.

A novel mutation in EROS (CYBC1) causes chronic granulomatous disease.

Chronic Granulomatous Disease (CGD) is an inborn error of immunity characterised by opportunistic infection and sterile granulomatous inflammation. CGD is caused by a failure of reactive oxygen species (ROS) production by the phagocyte NADPH oxidase. Mutations in the genes encoding phagocyte NADPH oxidase subunits cause CGD. We and others have described a novel form of CGD (CGD5) secondary to lack of EROS (CYBC1), a highly selective chaperone for gp91phox. EROS-deficient cells express minimal levels of gp91phox and its binding partner p22phox, but EROS also controls the expression of other proteins such as P2X7. The full nature of CGD5 is currently unknown. We describe a homozygous frameshift mutation in CYBC1 leading to CGD. Individuals who are heterozygous for this mutation are found in South Asian populations (allele frequency = 0.00006545), thus it is not a private mutation. Therefore, it is likely to be the underlying cause of other cases of CGD.

Quantum Unique Ergodicity for Cayley Graphs of Quasirandom Groups.

A finite group G is called C-quasirandom (by Gowers) if all non-trivial irreducible complex representations of G have dimension at least C. For any unit ℓ2 function on a finite group we associate the quantum probability measure on the group given by the absolute value squared of the function. We show that if a group is highly quasirandom, in the above sense, then any Cayley graph of this group has an orthonormal eigenbasis of the adjacency operator such that the quantum probability measures of the eigenfunctions put close to the correct proportion of their mass on suitably selected subsets of the group that are not too small.

Clinical Significance of Myositis-Specific and Myositis-Associated Antibody Profiles in Dermatomyositis.

Background: Myositis-specific autoantibodies (MSA) and myositis-associated autoantibodies (MAA) are clinically useful biomarkers that point to the diagnosis, clinical manifestations, and prognosis of dermatomyositis (DM). Materials and Methods: To estimate the prevalence of MSA as well as MAA and analyze possible clinical correlations of these autoantibodies in patients diagnosed with DM, we conducted a cross-sectional study of 30 patients who were diagnosed with DM. Results: MSA were positive in 19 patients (63%) in which Mi 2 was positive in 8 (27%) patients, and this was the most frequently found MSA. A total of 11 (36.7%) patients showed positive MAA. AntiPM/Scl 75 and anti-Ro 52 were positive in 5 (16.7%) patients each and these were the most commonly found MAA. Anti-La was absent in all our patients. There were 8 (27%) patients in whom both MSA and MAA were positive. Either MSA and/or MAA were positive in 22 (73%) patients. On a bivariate analysis, the patients who were positive for anti-PM/Scl 75 showed a significant difference in manifesting cutaneous ulcers (P value 0.023). It was also found that anti-SAE-positive patients showed a significant difference with malignancy (P value 0.014). Anti-Ro 52-positive patients were less likely to have symmetrical proximal muscle weakness (P value 0.006). Conclusions: All patients who were anti-MDA 5 positive had myositis and none of the anti-MDA 5-positive patients had rapidly progressive interstitial lung disease (RPILD). More than one MSA in the same patient was noted in three patients.

Hyaluronic acid rectal spacer in EBRT: Usability, safety and symmetry related to user experience.

OBJECTIVES: To report on the usability, safety, symmetry, and effectiveness of hyaluronic acid (HA) injected between the prostate and the rectum for patients undergoing treatment for prostate cancer with external beam radiotherapy (EBRT), and present a novel definition of rectal spacer symmetry that is reproducible and independent of patient anatomy. PATIENTS AND METHODS: 102 consecutive patients with clinical stage of T1c-3b prostate cancer underwent general anaesthesia for fiducial marker insertion and injection of HA into the perirectal space before EBRT. HA safety, symmetry, separation, and usability based on user experience were assessed. RESULTS: HA insertion was completed with a 100% success rate independent of user experience, rated as 'easy' or 'very easy' in all cases. There were no postoperative complications reported. The mean (SD) recto-prostatic separation for all patients at the base, midgland and apex were 12 (±2) mm, 11 (±2) mm, and 9 (±1) mm respectively. The mean sagittal length of the implant was 43 (±5) mm. The implant was rated as symmetrical in 98% of cases. The mean rV70Gy was 1.6% (IQR 0.8-3.3%) for patients receiving 78-80Gy. The mean rV53Gy was 2.8% (IQR 1.2-4.8%) for patients receiving 60-62Gy. The median prostate size was 43.5 cc (IQR 32-57). CONCLUSION: Injection of HA was able to achieve highly symmetrical recto-prostatic separation, with new users able to produce excellent separation, particularly at the apex, achieving similar dosimetry outcomes as competent and experienced users. HA is safe, easy to use, and significantly reduced mean rV70Gy and rV53Gy compared to non-spacer patients.

Active Symptom-Based Surveillance of Adverse Events Following Immunization Among Individuals Vaccinated with ChAdOx1 nCoV-19 Coronavirus Vaccine in a Tertiary Hospital of Kerala.

BACKGROUND: The reports on adverse experiences following vaccination are scanty from India. It is important to know the real-world post-vaccination experience outside of clinical trial conditions. OBJECTIVES: The study aims to estimate the incidence of adverse events following immunization with the ChAdOx1 nCoV-19 coronavirus vaccine and to identify the predictors for the development of vaccine adverse events. METHODS: A prospective observational study was conducted among health care workers who received the ChAdOx1 nCoV-19 coronavirus vaccine. Study participants were monitored at the site for 30 min following vaccination and were followed up for 7 days after receiving the second dose, with a purpose-specific designed online surveillance form to enquire about any adverse events following vaccination. We used the Chi-squared test for categorical variables and multivariate regression analysis to identify predictors for the development of vaccine adverse effects. RESULTS: Of 411 participants, the mean age was 30.77 ± 12.5 years and 76.2% were females. Overall, 207 (50.4%) respondents reported at least one post-vaccination symptom receiving either dose of coronavirus vaccination. Fever (34.8%), local pain at the injection site (28.0%), tiredness (25.5%), chills (20%), myalgia (18.7%), headache (17.8%), injection site stiffness (5.4%), joint pain (4.6%) and nausea-vomiting (3.8%) were the most prevalent symptoms following the first dose. Adverse reactions reported after the second dose were milder and less frequent. Postvaccination symptoms were more likely in the younger age group, those with comorbidity particularly, bronchial asthma , and a history of allergy to food/drugs. CONCLUSION: All the adverse reactions were of a minor type and non-serious. Side effects were less common in older adults (>60 years). Reactions to the second dose were lesser in intensity and frequency. Younger age, history of allergy, and comorbidities, particularly asthma, were found to be major predictors for the development of adverse events and require more watchful vaccine administration.

'More Than Just Skin in the Game'. DADA2 Autoinflammatory Syndrome and Stroke in the Young.

A 21-year-old man had a long-standing history of leg ulcers and hyperpigmention over the feet. Over a span of 8 months, he had an acute ischemic stroke followed by a basal ganglia hemorrhage. He was finally diagnosed with DADA2 syndrome after genetic sequencing. The implications of this new syndrome and its links to stroke in the young are presented in this article.

Hematotoxic Snakebite Victim with Trauma: The Role of Guided Transfusion, Rotational Thromboelastometry, and Tranexamic Acid.

Hematotoxic snake bite is a leading cause of mortality in South India. However, it is rare for the emergency physician to encounter a patient with trauma associated with snakebite. Management of such a patient differs substantially from the routine management of either a trauma patient or a snakebite victim. A 59-y-old man was bitten by a snake, after which he lost consciousness, fell, and sustained facial trauma. He was rushed to the emergency department within 30 min and was discovered to have ongoing oromaxillofacial bleeding. His respiratory distress and gasping respirations warranted orotracheal intubation and ventilation. He was treated with anti-snake venom and underwent viscoelastometry-guided transfusion to correct coagulopathy. Hemostasis was achieved after administration of tranexamic acid and bilateral posterior nasal packing. Imaging studies revealed craniomaxillofacial trauma with intracranial hemorrhage. He underwent a delayed mandibular repair. Judicious, guided fluid management, adequate nutrition, and prompt weaning off the ventilator allowed early discharge of the patient from the hospital. The minimal weakness present in his left lower limb at the time of discharge had improved by the time of follow-up. This report shows the utility of early and rapid anti-snake venom in envenomated victims with coagulopathy. The role of cryoprecipitate, tranexamic acid, and viscoelastometric testing needs further exploration in specific hematotoxic snakebites.

Aspergillus fumigatus meningitis in an immunocompetent young woman.

Aspergillus meningitis is a rare clinical entity that is much more frequently observed among immunocompetent patients. Here we present the case of a 28 year old immunocompetent lady with Aspergillus fumigatus meningitis possibly following spinal anaesthesia for her caesarean section. The diagnosis of Aspergillus meningitis is very difficult and challenging. Even after diagnosis, clinical outcomes remain poor with treatment. We wish to highlight the need for high index of suspicion for Fungal meningitis in patients presenting with meningism after Neurosurgeries and procedures involving invasion into the CSF compartment.

Possible Effects of Perchlorate Contamination of Drinking Water on Thyroid Health.

BACKGROUND: Perchlorate is an anion that occurs as a contaminant in groundwater. It originates from the improper disposal of ammonium perchlorate, a component of rocket fuel. The objective of this study was to explore whether the exposure to perchlorate in drinking water had an impact on the thyroid function of the population residing near an ammonium perchlorate plant in Kerala. Methodology. Using an ecological study design, we compared the serum levels of thyroid-stimulating hormone, thyroxine, and thyroid peroxidase antibodies among a representative sample of 289 study subjects from the area surrounding the ammonium perchlorate enrichment plant to 281 study subjects in a control area. RESULTS: The perchlorate concentration in the groundwater varied from 1600 ppb to 57,000 ppb in the 10 samples from the contaminated area and was below 24 ppb in all locations in the control area. No significant differences were found in the mean serum TSH concentration and mean T4 levels between the subjects from the contaminated area and the control area. On regression analysis, perchlorate contamination was not found to be a significant predictor of TSH. CONCLUSION: This study did not find any significant association between perchlorate in drinking water and changes in thyroid hormone levels. Our findings indicate the need for further investigation of this hypothesis using urinary perchlorate as a measure of individual exposure.