A clinical account of hospitalized 2009 pandemic influenza A (H1N1) cases.

OBJECTIVE: To determine the clinical characteristics in adults with confirmed pandemic influenza A (H1N1) infection 2009. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010. METHODOLOGY: Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction (RT-PCR) were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form. RESULTS: Mean age was 34.24±13.92 years with 61.1% females. Seventeen (47.2%) had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever (97.2%), cough (97.2%), rhinnorhea (80.6%), and shortness of breath (58.3%) were the commonest symptoms. Radiographic abnormalities were interstitial/reticular infiltrates (30.6%), patchy consolidations (11.1%) and reticular shadows with areas of consolidation (25%). PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase (CK) levels greater than 400 U/L and lactate dehydrogenase (LDH) levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay. CONCLUSION: The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A (H1N1) is vital to prevent the rapid disease progression.

Haematological Parameters And Outcome In Hospitalized Patients With Covid-19: A Developing Country Experience.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a multisystem disorder and haematological abnormalities are frequently documented in affected patients. METHODS: This retrospective study included 549 patients hospitalized with COVID-19 from 1st June to 15th July 2020 at Pak Emirates hospital, Rawalpindi Pakistan. p<0.05 was considered statistically significant. RESULTS: Median age was 60 years (range 12-94 years), males 442 (80.5%) and females 107 (19.5%). There was no patient with mild illness, 181 (32.9%) had moderate, 158 (28.7%) severe and 210 (38.2%) patients had critical disease. Patients with severe and critical disease had lower absolute lymphocyte count (ALC) and platelets (p<0.001 for both) while higher white blood cell count (WBC), neutrophil lymphocyte ratio (NLR), C-reactive protein (CRP), interleukin-6 (IL-6) and lactate dehydrogenase levels (LDH) levels (all p<0.001). Overall survival of study cohort was 83.2% (n=457). Median haemoglobin and platelet count were significantly lower (p<0.001) while WBC, ANC, NLR, prothrombin time (PT), activated partial thromboplastin time (APTT), ferritin, IL-6, LDH were significantly higher (p<0.001) for patients who died. On multivariate logistic regression analysis WBC count>10x109/l (odds ratio [OR] 2.19 [95% CI 1.3-4.2] p=0.01), NLR>9 (OR 3.4 [95% CI 0.87-6.8], p<0.001), platelets<150x109/l (OR 3.9 [95% CI 1.4-9.8] p<0.001), CRP >100; (OR 4.1[95% CI 0.78-10.9] p<0.001) and ferritin >1000 (OR 5.3 [95% CI 1.9- 13.5], p<0.001) were associated with increased risk of death in patients with COVID-19. CONCLUSION: Monitoring of haematological, coagulation and inflammatory parameters provide reliable, convenient, rapid and cost-effective method for predicting disease severity, complications and prognosis of COVID-19 patients.

Clearing the Fog: Is Hydroxychloroquine Effective in Reducing Coronavirus Disease-2019 Progression? A Randomized Controlled Trial.

Background Hydroxychloroquine (HCQ) has been considered for the treatment of coronavirus disease 2019 (COVID-19), but data on its efficacy are conflicting. We analyzed the efficacy of HCQ along with standard of care (SOC) treatment, compared with SOC alone, in reducing disease progression in mild COVID-19. Methods A single-center open-label randomized controlled trial was conducted from April 10 to May 31, 2020 at Pak Emirates Military Hospital, Rawalpindi. Five hundred patients of both genders between the ages of 18 and 80 years with mild COVID-19 were enrolled in the study. A total of 349 patients were assigned to the intervention group (standard dose of HCQ plus SOC) and 151 patients were assigned to SOC only. The primary outcome was progression of disease while secondary outcome was polymerase chain reaction (PCR) negativity on days 7 and 14. The results were analyzed on Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY) version 23. A p-value <0.05 was considered significant.  Results The median age of the intervention group was 34 ± 11.778 years and control group was 34 ± 9.813 years. Disease progressed in 16 patients, 11 (3.15%) of which were in the intervention group and 5 (3.3%) in the control group (p-value = 0.940). PCR negative cases in intervention and control groups on day 7 were 182 (52.1%) and 54 (35.8%), respectively (p-value = 0.001); and on day 14 were 244 (69.9%) and 110 (72.9%), respectively (p-value = 0.508). Consecutive PCR negativity on days 7 and 14 was observed in 240 (68.8%) patients in the intervention group compared to 106 (70.2%) in the control group (p-value = 0.321). Conclusion The addition of HCQ to SOC in hospitalized mild COVID-19 patients neither stops disease progression nor helps in early and sustained viral clearance.

Therapeutic plasma exchange for coronavirus disease-2019 triggered cytokine release syndrome; a retrospective propensity matched control study.

BACKGROUND: Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. OBJECTIVE: To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. METHODOLOGY: Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. RESULTS: After PS-matching, the selected cohort had a median age of 60 years (range 32-73 in TPE, 37-75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3-22 days' TPE and 3-20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33-97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29-78.76 (log rank 0.002), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th day (p = 0.0045). CONCLUSION: An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

CALL Score and RAS Score as Predictive Models for Coronavirus Disease 2019.

BACKGROUND:  Coronavirus disease 2019 (COVID-19) is a novel infectious disease of multi-system involvement with significant pulmonary manifestations. So far, many prognostic models have been introduced to guide treatment and resource management. However, data on the impact of measurable respiratory parameters associated with the disease are scarce. OBJECTIVE:  To demonstrate the role of Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase (CALL) score and to introduce Respiratory Assessment Scoring (RAS) model in predicting disease progression and mortality in COVID-19. METHODOLOGY:  Data of 252 confirmed COVID-19 patients were collected at Pak Emirates Military Hospital (PEMH) from 10th April 2020 to 31st August 2020. The CALL score and proposed factors of RAS model, namely respiratory rate, oxygen saturation at rest, alveolar arterial gradient and minimal exercise desaturation test, were calculated on the day of admission. Progression of disease was defined and correlated with measured variables. Univariate and multivariate Cox regression analysis for each variable, its hazard ratio (HR) and 95% confidence interval (CI) were calculated, and a nomogram was made using the high-risk respiratory parameters to establish the RAS model. RESULTS:  Progression of disease and death was observed in 124 (49.2%) and 49 (19.4%) patients, respectively. Presence of more than 50% of chest infiltrates was significantly associated with worsening disease and death (p-value <0.001). Death was observed in 100% of patients who had critical disease category on presentation. Regression analysis showed that the presence of comorbidity (n: 180), in contrast to other variables of CALL score, was not a good prognosticator of disease severity (p-value: 0.565). Nonetheless, the CALL model itself was validated to be a reliable prognostic indicator of disease progression and mortality. Some 10 feet oxygen desaturation test (HR: 0.99, 95%CI: 0.95-1.04, p--value: 0.706) was not a powerful predictor of the progression of disease. However, respiratory rate of more than 30 breaths/minute (b/m) (HR: 3.03, 95%CI: 1.77-5.19), resting oxygen saturation of less than 90% (HR: 2.41, 95%CI: 1.15-5.06), and an elevated alveolar-arterial oxygen gradient (HR: 2.14, 95%CI: 1.04-4.39) were considered statistically significant high-risk predictors of disease progression and death, in the formed RAS model. The model resulted in 85% (95%CI: 80%-89%) of area under the receiver operating characteristic curve (AUROC), with substantial positive (76%, 95%CI: 68%-83%) and negative predictive values (80%, 95%CI: 73%-87%) for a cutoff value of seven. Patients with higher CALL and RAS scores also resulted in higher mortality. CONCLUSION:  CALL and RAS scores were strongly associated with progression and mortality in patients with COVID-19.

Diacetylmorphine (heroin) body packer presenting with respiratory arrest.

Intracorporeal concealment of illicit drugs known as 'body packing' is uncommonly reported. A body packer with swallowed capsules containing Diacetylmorphine (heroin) for smuggling purposes presented with respiratory arrest and recovered after ventilatory support and nalaxone infusion.

Comparison of diagnostic yield of AFB with sputum induction to spontaneous sputum examination in suspected pulmonary tuberculosis.

OBJECTIVE: To compare the diagnostic yield of AFB positivity with sputum induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Military Hospital, Rawalpindi, from January to December 2006. METHODOLOGY: Sputum specimens were collected by both techniques from 164 patients with clinical and radiological suspicion of pulmonary tuberculosis admitted in medical wards. All specimens were examined for AFB smear and culture positivity. Sputum induction was done for 15-20 minutes with 3% sterile hypertonic saline solution by nebulization in all cases. Proportions were compared using Chi-square test. RESULTS: Among 164 patients, 32 patients (19.5%) were not expectorating spontaneously. Sputum induction was successful in 22 (68.75%) cases and AFB smear was positive in 03 (9.37%) and AFB culture was positive in 7 (21.8%) of these cases. One hundred and thirty two (80.5%) patients were already expectorating and both Day-1 (spontaneous) and Day-2 (induced) sputum samples were available. Day-1 (spontaneous) sputum specimens revealed AFB smear positive results in 20 (15.15%) patients, and AFB culture positive results in 24 (18.18%) patients. Smear positivity on Day-2 (induced) sputum samples was 21.21% (28) with 27.27% (36) culture positivity. CONCLUSION: In expectorating patients, AFB smear and culture positivity results remain comparable with spontaneous and induced sputum sampling. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample.

Retrospective audit of patients treated for MDR-TB in re-treatment category.

OBJECTIVE: To determine the efficacy of our modified anti-tuberculosis regimen in adult patients with multi-drug-resistant tuberculosis (MDR-TB) in the re-treatment category. METHODS: Retrospective chart review of 176 patients in re-treatment category with diagnosis of MDR-TB from 1st Jan 1993 to 31st Dec 2002 managed at the Department of Pulmonology Military Hospital Rawalpindi, Pakistan. All the patients were given four standard first line anti-TB drugs along with any two second line drugs out of Ofloxacin/Ciprofloxacin/Levofloxacin, Amikacin, or Clarithromycin and treatment was modified after availability of drug susceptibility testing (DST). RESULTS: Seventy-two percent of the patients were young men with mean age of 32.28 +/- 8.7 yrs, 53.4% had moderately advanced while nearly 30% had extensive disease. One-third cases had contact with a patient of pulmonary tuberculosis out of which one fifth had contact with a MDR-TB patient. Mean duration of diagnosis of tuberculosis before therapy was 41.11 +/- 14.32 months and 70% of the cases had received at least 2 prior anti-TB regimens. They had received a median of four anti-TB drugs in past and were infected with organisms that were resistant to a median of 3 first line anti-TB drugs. Resistance to Ethambutol and PZA was about 18% and 11% respectively. A median of six anti-TB drugs was used while mean duration of therapy was 22.17 +/- 2.17 months. Bacteriological cure was achieved in about 90% cases while radiological response was documented in nearly 78%. CONCLUSION: Modified initial management strategy followed by DST guided therapy has yielded excellent results and needs to be assessed in further trials for wider application.

High resolution computed tomographic patterns in adults with pulmonary tuberculosis.

OBJECTIVE: To determine the High Resolution Computed Tomographic (HRCT) patterns in adults with Acid Fast Bacillus (AFB) positive new cases of Pulmonary Tuberculosis (PTB). STUDY DESIGN: A descriptive case series. PLACE AND DURATION OF STUDY: The study was carried out at the Department of Pulmonology and Department of Radiology, Military Hospital, Rawalpindi, from June 2006 to August 2007. METHODOLOGY: Fifty adults with AFB positive new pulmonary tuberculosis were included in the study, while PTB cases in the retreatment category, Multi Drug Resistant (MDR) tuberculosis, PTB with Chronic Obstructive Airways Disease (COPD), pneumoconiosis, Diffuse Parenchymal Lung Diseases (DPLDs) etc. were excluded. All cases underwent HRCT chest with 2 mm collimations at 10 mm intervals. Relevant data was collected on a pre-designed patient proforma. RESULTS: The mean age was 40.18 +/- 14.55 years with 88% males; 46% and 30% samples were sputum and endobronchial washings smear positive for AFB respectively, while the rest were culture positive. HRCT findings included centrilobular nodules in 92% cases, lobular consolidation in 84%, cavitation in 76%, 'tree-in-bud' appearance in 68%, lymphadenopathy in 8% and miliary nodules in 4% cases. HRCT patterns included centrilobular nodules and lobular consolidation in 80% cases, while centrilobular nodules with cavitation and centrilobular nodules with 'tree-in-bud' appearance were noted in 72% and 68% patients respectively. Thirty two (64%) cases had centrilobular nodules, cavitation and lobular consolidations and about half cases had centrilobular nodules, 'tree-in-bud' appearance and lobular consolidation. CONCLUSION: Centrilobular nodules and lobular consolidations (80%), centrilobular nodules with cavitation (72%) and centrilobular nodules with 'tree-in-bud' appearance (68%) were the most common HRCT patterns in adults newly diagnosed with pulmonary tuberculosis.

Diagnostic yield of transbronchial needle aspiration--analysis of 30 cases.

BACKGROUND: In our clinical set up transbonchial needle aspiration of lymph node and parenchymal lesions is an underutilized technique. This study was done to highlight the usefulness of this technique in the pulmonologists armamentarium. METHODS: Thirty procedures were performed on patients with intrathoracic lymphadenopathy or parenchymal lung lesions in this study from October, 2006 to April, 2007. Patients with an easily accessible peripheral lymph node, bleeding diathesis and an already confirmed diagnosis were excluded from the study as were patients with a well visualized biopsiable endobronchial lesion. RESULTS: Nineteen patients (63.3%) on whom transbonchial needle aspirations were performed had intrathoracic lymphadenopathy while 11 (36.6%) had parenchymal lesions without endobronchial lesions which could be biopsied. Adequate samples were obtained in 23 patients (76.6%) chronic granulomatous inflammations which was diagnosed as tuberculosis in corroboration with other clinical and laboratory evidence was seen in 3 cases (10%). Carcinoma was diagnosed in 6 cases (20%). Thirteen cases (43%) were reported as normal and inadequate samples were obtained in 7 cases (23%). CONCLUSION: Transbronchial Needle Aspiration (TBNA) is an effective method of obtaining cytological material from intrathoracic lymph nodes and parenchymal lesions and can provide a safe alternative to invasive mediastinotomy/mediastinoscopy and open lung biopsy.

Percutaneous Tracheostomy by Physician Intensivists.

OBJECTIVE: To assess the safety of percutaneous tracheostomy when performed by physician intensivists. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Adult Medical ICU in the Department of Critical Care Medicine, Military Hospital, Rawalpindi, Pakistan, from September 2013 to August 2016. METHODOLOGY: Departmental record for percutaneous tracheostomies, performed by physician intensivifts, was evaluated. Variables studied were underlying primary diagnosis, details of the operating doctors, presence of immediate complications, departmental protocol for the procedure, pre-procedure safety checklist, written instructions on procedure steps, use of ultrasound and bronchoscopy. Portex Percutaneous Dilation Tracheostomy Kit with Single-Stage Dilator was used in all the patients. RESULTS: Fifty-six percutaneous tracheostomy procedures were performed with a male to female ratio 3:1; more than 2/3rd (80%) had an underlying neurological illness. All doctors performing the procedures were physicians having minimum qualification of Fellowship with at least one year experience in intensive care and had observed at least five procedures. Departmental protocol for the procedure was followed in all the cases. Minor complications were observed in three patients (5.35%). These included para-tracheal misplacement, accidental de-cannulation, and endotracheal tube cuff puncture. None of the patient died due to direct complications of the procedure. CONCLUSION: Percutaneous tracheostomy is safe in Medical ICUs of developing countries, when performed by experienced physician intensivists under defined protocols.

Necrotizing fasciitis in an immunocompetent patient with multiple sites of involvement.

Necrotizing fasciitis (NF) in an immunocompetent patient with multiple sites of involvement is very rare. We describe a case of E. coli associated necrotizing fasciitis in a middle aged female with three lesions of NF on her lower limbs at the time of presentation. She was managed with broad spectrum intravenous antibiotics, radical surgical debridements with skin grafting, and aggressive supportive care.

Right ventricular myxoma with heart failure.

Cardiac myxomas are histologically benign tumors but they may be lethal because of their strategic position. These are mostly located in the left atrium and uncommonly in the right atrium. We report a case of a large right ventricular myxoma presenting with heart failure.

Sputum neutrophilia in severe persistent asthmatics.

OBJECTIVE: To determine the frequency of sputum neutrophilia in patients with severe persistent bronchial asthma. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Department of Medicine, Military Hospital, Rawalpindi, from November 2009 to November 2010. METHODOLOGY: Cases of severe persistent bronchial asthma, aged between 12 and 40 years, were included. Sputum samples were collected by induction with hypertonic saline (4.5%). All samples were centrifuged and differential neutrophil count was calculated. Data was analyzed using SPSS 11. RESULTS: Out of 195 patients, there were 129 (66.2%) males and 66 (33.8%) females. The mean age was 27.01 ± 6.92 years. Mean sputum neutrophilic count was 126.47 ± 16.52 x 106/ml and the mean neutrophilic percentage was 63.187 ± 8.3363. Sputum neutrophilia was present in 84 patients (43.1%), out of whom, 56 were males and 28 females. In patients with sputum neutrophilia, mean neutrophilic count was 142.40 ± 8.49 x 106/ml and the mean neutrophilic percentage was 71.2024 ± 4.2441%. CONCLUSION: Sputum neutrophilia is a frequent finding in cases with severe persistent bronchial asthma. Presence of sputum neutrophilia in such cases can lessen the inappropriate use of corticosteroids with their associated long-term side effects.