Dextromethorphan premedication in the alleviation of cough during flexible bronchoscopy in adults: A randomized double-blind placebo-controlled trial.

BACKGROUND AND OBJECTIVE: Cough is invariably encountered during flexible bronchoscopy despite sedation and topical anaesthetics. The ideal cough suppressant during flexible bronchoscopy is not known. We assessed the role of dextromethorphan premedication in relieving the cough during flexible bronchoscopy in adults. METHODS: In this single-centre study, we randomized patients aged ≥18 years to receive dextromethorphan syrup 30 ml (90 mg) or an equal volume of placebo 1 h before the procedure. Patients rated their cough severity and discomfort on a visual analogue scale at the end of the procedure. Bronchoscopists also rated cough severity at the end of the procedure. RESULTS: Out of 112 patients screened, 94 patients (median (interquartile range [IQR]) age 51 (36.25-60.75) years, male: female 2.13:1) were randomized to either the dextromethorphan (n = 47) or placebo (n = 47) groups. The patients-rated median (IQR) cough scores at the end of the procedure were 15 (10-23) mm in dextromethorphan versus 20 (12-45.5) mm in placebo groups (p = 0.03). Patients-rated median cough scores at 1 h (5 mm vs. 6 mm, p = 0.21), discomfort scores (12.5 mm vs. 12.5 mm, p = 0.49), and midazolam and lignocaine usage were similar between the two groups. The bronchoscopist-rated median cough score was non-significantly lower in the intervention compared to the placebo (26 mm vs. 35 mm, p = 0.09) groups. CONCLUSION: Dextromethorphan premedication 1 h before flexible bronchoscopy may have an additive effect on cough suppression under conscious sedation and topical lignocaine. Further trials are needed to reiterate our findings with certainty.

Letter in Response to "Melioidosis in a Tertiary Care Center from South India: A 5-year Experience.

How to cite this article: Behera B, Mohanty S, Mishra B, Mohapatra PR. Letter in Response to "Melioidosis in a Tertiary Care Center from South India: A 5-year Experience. Indian J Crit Care Med 2023;27(5):368-369.

Spectrum of Bacterial Pathogens in Critical COVID-19 Patients Admitted in Intensive Care Units of a Tertiary Care Hospital During the First and Second Wave of the Pandemic.

OBJECTIVE: This study intends to compare the clinical characteristics and the prevalence and spectrum of bacterial pathogens in COVID-19 patients admitted to ICU during the first and second waves at a tertiary care, teaching and referral hospital of eastern India. METHOD: This is a hospital-based retrospective study which analysed demographic details, clinical profile and bacterial culture results of severe and critically ill COVID-19 patients admitted in intensive care units (ICU) during April -Oct 2020 (1st wave) and April -July 2021 (2nd wave). RESULT: The patients admitted during the 2nd wave were comparatively older and had multiple comorbidities compared to the 1st wave. (23.8%) (45/189) and 50% (173/346) of the COVID-19 patients admitted to ICU developed bacterial infection during the 1st and 2nd wave respectively. Overall, there was predominance of multidrug resistant Gram negative bacilli in both the waves. There was increased isolation of intrinsic colistin resistant microorganisms. CONCLUSION: Multidrug resistant Gram negative bacterial infections, remain a dreaded complication in severe and critically ill hospitalised COVID-19 patients requiring ICU care and high usage of colistin spirals the emergence and spread of pathogens intrinsically resistant to colistin.

Utility of endobronchial ultrasound guided trans-bronchial needle aspiration in diagnosis of melioidosis - case series and review of literature.

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is routinely performed for diagnostic evaluation of mediastinal lymphadenopathy due to various etiologies with excellent sensitivity and specificity. Melioidosis can have atypical features like isolated mediastinal lymphadenopathy mimicking as tuberculosis or lymphoma. Differentiation of such atypical melioidosis presentation become difficult due to similar clinical, radiological and even similar EBUS lymph node characteristics. Role of EBUS TBNA in diagnosing melioidosis is under investigated and sparsely reported. We describe two cases of melioidosis diagnosed by point of care rapid lateral flow immunoassay antigen testing and culture of EBUS-TBNA samples from necrotic mediastinal lymph nodes.

A case of systemic melioidosis: unravelling the etiology of chronic unexplained fever with multiple presentations.

Melioidosis, caused by the environmental saprophyte, Burkholderia pseudomallei, is an important public health problem in Southeast Asia and Northern Australia. It is being increasingly reported from other parts, including India, China, and North and South America expanding the endemic zone of the disease. We report a case of systemic melioidosis in a 58-year-old diabetic, occupationally-unexposed male patient, who presented with chronic fever, sepsis, pneumonia, pleural effusion and subcutaneous abscess, was undiagnosed for long, misidentified as Pseudomonas aeruginosa infection elsewhere, but was saved due to correct identification of the etiologic agent and timely institution of appropriate therapy at our institute. A strong clinical and microbiological suspicion for melioidosis should be considered in the differential diagnosis of acute pyrexia of unknown origin, acute respiratory distress syndrome and acute onset of sepsis, especially in the tropics.

Microbiological profile of long COVID and associated clinical and radiological findings: a prospective cross-sectional study.

OBJECTIVE: To study the frequency of microbiological etiology of respiratory infections in patients with long COVID and their associated clinical and radiological findings. METHODS: Nasopharyngeal swabs and sputum specimens were collected from 97 patients with respiratory illness stemming from long COVID. The specimens were assessed for their microbiological profile (bacteria and virus) and their association with the overall clinical and radiological picture. RESULTS: In total, 23 (24%) patients with long COVID had viral infection (n = 12), bacterial infection (n = 9), or coinfection (n = 2). Microorganisms were detected at significantly higher rates in hospitalized patients, patients with moderate COVID-19, and patients with asthma (P < .05). Tachycardia (65%) was the most common symptom at presentation. A statistically significant number of patients with long COVID who had viral infection presented with cough and myalgia; and a statistically significant number of patients with long COVID who had bacterial infection presented with productive coughing (P < .05). Post-COVID fibrotic changes were found in 61% of cohort patients (31/51). CONCLUSION: A decreasing trend of respiratory pathogens (enveloped viruses and bacteria) was found in long COVID. An analysis including a larger group of viral- or bacterial-infected patients with long COVID is needed to obtain high-level evidence on the presenting symptoms (cough, myalgia) and their association with the underlying comorbidities and severity.

Ruptured Pulmonary Hydatid Cyst.

A 37-year-old male presented with left-sided hydropneumothorax. After drainage of fluid and air from the pleural cavity, chest radiograph and computed tomography of chest showed characteristic radiological image of ruptured hydatid cyst. The diagnosis was supported by positive echinococcal serology.

Community-Acquired burkholderia cepacia complex (BCC) pneumonia in a lung cancer patient on erlotinib.

Community-acquired Burkholderia cepacia pneumonia is uncommon. We report a 32-year-old female who was on oral erlotinib, a tyrosine kinase inhibitor, for 2 years for her lung cancer and developed community-acquired Burkholderia cepacia pneumonia, which was confirmed by blood culture. The patient improved with antibiotics.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study.

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Post COVID sequelae among COVID-19 survivors: insights from the Indian National Clinical Registry for COVID-19.

INTRODUCTION: The effects of COVID-19 infection persist beyond the active phase. Comprehensive description and analysis of the post COVID sequelae in various population groups are critical to minimise the long-term morbidity and mortality associated with COVID-19. This analysis was conducted with an objective to estimate the frequency of post COVID sequelae and subsequently, design a framework for holistic management of post COVID morbidities. METHODS: Follow-up data collected as part of a registry-based observational study in 31 hospitals across India since September 2020-October 2022 were used for analysis. All consenting hospitalised patients with COVID-19 are telephonically followed up for up to 1 year post-discharge, using a prestructured form focused on symptom reporting. RESULTS: Dyspnoea, fatigue and mental health issues were reported among 18.6%, 10.5% and 9.3% of the 8042 participants at first follow-up of 30-60 days post-discharge, respectively, which reduced to 11.9%, 6.6% and 9%, respectively, at 1-year follow-up in 2192 participants. Patients who died within 90 days post-discharge were significantly older (adjusted OR (aOR): 1.02, 95% CI: 1.01, 1.03), with at least one comorbidity (aOR: 1.76, 95% CI: 1.31, 2.35), and a higher proportion had required intensive care unit admission during the initial hospitalisation due to COVID-19 (aOR: 1.49, 95% CI: 1.08, 2.06) and were discharged at WHO ordinal scale 6-7 (aOR: 49.13 95% CI: 25.43, 94.92). Anti-SARS-CoV-2 vaccination (at least one dose) was protective against such post-discharge mortality (aOR: 0.19, 95% CI: 0.01, 0.03). CONCLUSION: Hospitalised patients with COVID-19 experience a variety of long-term sequelae after discharge from hospitals which persists although in reduced proportions until 12 months post-discharge. Developing a holistic management framework with engagement of care outreach workers as well as teleconsultation is a way forward in effective management of post COVID morbidities as well as reducing mortality.

Prevention of melioidosis.

Melioidosis is a complex tropical disease linked with many complications. It is increasingly diagnosed in India. The clinical mimicry of this disease with several other common causes of pneumonia has kept the clinicians in ignorance. Usually, the diagnosis and appropriate management get delayed. The organism closely resembles the common contaminant Pseudomonas and is easily misidentified in microbiology laboratories. The diagnosis is often missed because of poor diagnostic sensitivity of blood culture, the gold standard of the diagnosis. All this contributes to increased morbidity and mortality. The rampant use of high-end broad-spectrum antibiotics like ceftazidime and meropenem at suboptimal dose and duration suppresses the diagnosis without eradicating the disease, leaving the chance of recurrence from its latency even after years. As an infectious disease, the cure and prevention depend on early diagnosis and treatment. An awareness of its peculiar presentations and history can differentiate clinically and suspect the condition much easily from other mimickers of tuberculosis to sepsis. Ultimately, the prevention of melioidosis remains the critical strategy. Increasing the number of cases and intricated management of this fatal but potentially curable disease had prompted us to take up the mission of preventing the disease by spreading knowledge and awareness.

A rare case of hemoptysis.

A 39-year-old nonsmoker male presented with complaints of cough with recurrent mild hemoptysis. Computed tomography of thorax showed nodular lesions on the right lateral wall of trachea. Fiber-optic bronchoscopy revealed multiple nodular lesions on the right lateral wall of lower one-third of trachea. Histopathological examination of biopsy specimen from the nodules was suggestive of tracheobronchopathia osteochondroplastica which is an uncommon airway disorder.

Clinical presentations of nontuberculous mycobacteria as suspected and drug-resistant tuberculosis: Experience from a tertiary care center in Eastern India.

Background: Nontuberculous mycobacteria (NTM) are on the rise worldwide. The diagnosis and treatment of NTM disease create a dilemma for physicians as their clinical features often overlap with that of tuberculosis (TB). The present study aims to report a series of NTM infections presenting as suspected TB. Methods: It was a prospective observational study starting from December 2018 to January 2022. A total of 1850 suspected TB patients (pulmonary = 522 and extrapulmonary = 1328) were included in this study. Clinical features, radiological findings, microbiological diagnosis, treatment, and outcome were recorded. Clinical specimens were processed for Ziehl-Neelsen staining, GeneXpert MTB/Rif assay by cartridge-based nucleic acid amplification test, and culture. The culture-positive isolates were categorized as Mycobacterium tuberculosis complex or NTM depending on the detection of MPT64 antigen by immunochromatographic test. The NTM isolates were speciated by line probe assay using GenoType® Mycobacterium common mycobacteria kit. The criteria of the American Thoracic Society/Infectious Diseases Society of America were applied to confirm NTM disease. Results: Of 1850 suspected TB patients, NTM disease was diagnosed in 20 patients (pulmonary = 9, nonpulmonary = 11). Eight NTM cases presented as suspected drug-resistant-TB with a history of antitubercular therapy. Among pulmonary NTM cases, Mycobacterium scrofulaceum (n = 7) was the most common species followed by Mycobacterium kansasii (n = 1) and Mycobacterium intracellulare (n = 1). In nonpulmonary cases, Mycobacterium abscessus (n = 8) was involved in majority of cases followed by Mycobacterium fortuitum (n = 3). Cavitary lung disease and laparoscopic port site infections were most frequent pulmonary and non-pulmonary manifestations respectively. Conclusion: Hence, there is an urgent need for better diagnostic and drug susceptibility testing facility along with standardized treatment protocol for NTM disease.

Case Report: Multiple Scalp Abscesses due to Mycobacterium abscessus Infection Following Triamcinolone Injection in an Immunocompetent Person.

Mycobacterium abscessus complex is a group of nontuberculous mycobacteria (NTM). The NTM may involve skin, soft tissue, and other organs like the eye and central nervous system. Clinically may mimic multidrug resistance. Here, we present a case of a 29-year man with a history of multiple scalp swellings with mild symptoms. He had undergone multiple triamcinolone acetonide injections on his scalp to stop hair fall and baldness 2 months prior. As there was a history of injections on the scalp and lesions associated with minimal symptoms, we suspected the possibility of NTM and fungal infections. As a part of treatment and obtaining a sample for investigation, lesions were aspirated with a needle. The swellings contained gelatinous material, which was sent for microscopic examination, and revealed the presence of acid-fast bacilli (AFB). Xpert MTB/RIF assay was negative for mycobacteria (MTB complex), but culture revealed NTM, identified as M. abscessus complex by line probe assay. Based on the diagnosis, the patient was treated with an injection of amikacin, moxifloxacin, and azithromycin. The lesions improved. The patient has completed over a year of follow-up with no recurrence noted. Mycobacterium abscessus, a rapidly growing NTM, has been occasionally reported to cause cutaneous soft tissue infection when injected with nonsterile medicine or needles. Therefore, a high index of suspicion for NTM infection is warranted in patients with cutaneous scalp abscess following scalp injections for hair loss.