Shades of Blue: A Case Series of Acquired Methemoglobinemia.

Acquired methemoglobinemia (MetHb) is a rare but potentially life-threatening condition that has varied etiology, usually toxin- or drug-induced. We had five cases of acquired methemoglobinemia during six months. Their presentation varied from an asymptomatic state to respiratory distress. The presence of cyanosis and low oxygen saturation (SpO2), despite normal partial pressure of oxygen (PaO2) and chocolate brown-colored blood, were diagnostic clues present in all cases. A high level of methemoglobinemia was detected on arterial blood gas (ABG), confirming the diagnosis. Methylene blue was used as an antidote along with supportive care in symptomatic cases. All these cases of methemoglobinemia recovered completely. A high index of suspicion for methemoglobinemia should be maintained in cases presenting with persistent hypoxia or cyanosis despite normal PaO2.

Uncovering the Unusual: A Case of Mixed Connective Tissue Disease With Rare Presentation, Atypical Complications, and Therapeutic Dilemmas.

Mixed connective tissue disease (MCTD) is an overlap syndrome characterized by features of systemic lupus erythematosus, scleroderma, and polymyositis, along with the presence of the U1RNP antibody. A 46-year-old female patient presented with severe anemia, cough, and breathlessness, and was diagnosed with cold agglutinin disease, a type of autoimmune hemolytic anemia (AIHA). Autoimmune workup revealed MCTD by positive antinuclear and U1RNP antibodies. She had bilateral miliary mottling on X-ray and a tree-in-bud appearance on high-resolution computed tomography of the thorax, which were suggestive of pulmonary tuberculosis. Standard therapy with steroids was not advisable. She was subsequently started on anti-tuberculosis treatment (anti-Koch's therapy), followed by steroid therapy and immunosuppressive therapy after three weeks. The patient responded well to treatment, but after two months, she developed cytomegalovirus (CMV) retinitis. Adult-onset CMV disease may occur as a result of primary infection, reinfection, or activation of a latent infection. Although not directly related, it can occur as an atypical association in the setting of immunosuppressive therapy. Morbidity and mortality are significantly increased in this population secondary to infectious potentiation: immunosuppression causes infections, and infections cause AIHA. The management of MCTD and secondary AIHA and immunosuppression poses a therapeutic challenge.

Association of vitamin D with the severity of disease and mortality in COVID-19: Prospective study in central India.

Background: Many factors have been proposed to be associated with the severity of disease and mortality in COVID-19. Vitamin D had recently been reviewed as one of these factors. Aim and Objectives: To evaluate the association between Vitamin D and the disease severity and mortality in COVID-19. Materials and Methods: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in selected tertiary care teaching medical institutes of Central India. Participants were COVID-19 patients of the age group of 18 years and above admitted during the study period. They were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. Serum level of Vitamin 25(OH) D was measured using chemiluminescent immunoassay. The outcome of the disease was classified as recovery and death during hospitalization. The association of sociodemographic and medical characteristics with treatment outcome was studied using an appropriate statistical test. A full logistic regression model was built for the assessment of the relationship between treatment outcomes with Vitamin D level. Further, one receiver operating characteristic curve was developed to examine the prognostic significance of Vitamin D levels in COVID-19 patients. Results: Out of 748 enrolled patients, 44 (5.88%), had severe disease (Group D). A total of 721 cases (96.39%) recovered and were discharged, whereas 27 (3.61%) died during hospitalization. Mean Vitamin D level was found to be significantly different in discharged patients compared to those who were deceased. Increasing age-adjusted odds ratio (AOR) (95% confidence interval [CI]=1.07 [1.02-1.12]), known hypertension AOR (95%CI) = 3.38 (1.13-10.08), and diabetes mellitus AOR (95%CI) =28.5 (6.04-134.13) were found to be significant predictors of death among COVID-19 patients. Increasing Vitamin D level was found to be protective against COVID-19-related death (AOR (95% CI = 0.87 [0.80-0.94]). Conclusion: Vitamin D was significantly associated with the disease severity and mortality in COVID-19.

Résumé Contexte: Il a été proposé que de nombreux facteurs soient associés à la gravité de la maladie et de la mortalité dans le Covid - 19. La vitamine D avait récemment été examinée comme l'un de ces facteurs. Objectif et objectifs: évaluer l'association entre la vitamine D et la gravité de la maladie et la mortalité dans le Covid-19. Matériel et méthodes: Après l'approbation du comité d'éthique institutionnel, cette étude de cohorte prospective a été réalisée dans des instituts médicaux d'enseignement des soins tertiaires de l'Inde centrale. Les participants étaient des patients Covid-19 du groupe d'âge de 18 ans et plus admis au cours de la période d'étude. Ils ont été classés en quatre groupes comme asymptomatiques (groupe A), légers (groupe B), modérés (groupe C) et sévères (groupe D) sur la base des symptômes cliniques, de la fréquence respiratoire, de la saturation en oxygène et de l'imagerie thoracique. Niveau sérique de la vitamine 25 (OH) DWAS mesuré en utilisant l'immunodosage chimioluminescent. L'issue de la maladie a été classée comme récupération et décès pendant l'hospitalisation. L'association des caractéristiques sociodémographiques et médicales avec les résultats du traitement a été étudiée à l'aide d'un test statistique approprié. Un modèle de régression logistique complet a été construit pour l'évaluation de la relation entre les résultats du traitement au niveau de la vitamine D. De plus, une courbe caractéristique de fonctionnement du récepteur a été développée pour examiner la signification pronostique des niveaux de vitamine D chez les patients COVID-19. Résultats: Sur 748 patients inscrits, 44 (5,88%), avaient une maladie grave (groupe D). Un total de 721 cas (96,39%) ont récupéré et ont été libérés, tandis que 27 (3,61%) sont décédés pendant l'hospitalisation. Le niveau moyen de la vitamine D s'est révélé significativement différent chez les patients libérés par rapport à ceux qui ont été décédés. Augmentation du rapport de cotes ajusté à l'âge (AOR) (intervalle de confiance à 95% [IC] = 1,07 [1,02­1,12]), hypertension connue AOR (IC à 95%) = 3,38 (1,13­10,08) et diabète mellite aor (IC 95% ) = 28,5 (6,04­134.13) se sont révélés être des prédicteurs significatifs de la mort chez les patients COVID-19. L'augmentation du niveau de vitamine D s'est avérée protectrice contre la mort liée au Covid - 19 (AOR (IC à 95% = 0,87 [0,80­0,94]). Conclusion: La vitamine D était significativement associée à la gravité de la maladie et à la mortalité dans le Covid - 19. Mots clés: Covid - 19, tempête de cytokines, mortalité, gravité, vitamine D.

Neutrophil-to-Lymphocyte Ratio as a Predictor of Disease Severity and Mortality in Coronavirus Disease 2019: Prospective Study From Central India.

BACKGROUND: Clinical presentation of coronavirus disease 2019 (COVID-19) varies from an asymptomatic state to severe disease characterized by acute respiratory distress syndrome, respiratory failure, thrombosis, and multi-organ dysfunction syndrome. The neutrophil-to-lymphocyte ratio (NLR) has been reviewed as one of the laboratory factors that have been proposed to predict the severity of disease and mortality in COVID-19 pandemic. AIM AND OBJECTIVES: To evaluate the association between NLR and the disease severity and mortality in COVID-19. MATERIALS AND METHODS: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in a tertiary-care teaching medical institute of Central India. COVID-19 patients of the age group 18 years and above admitted during the study period were included. Cases were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. NLR was calculated by doing a complete blood count at the time of hospitalization by the Mindray BC-6000 auto hematology analyzer. The outcome of the disease was classified as recovery and death during hospitalization. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of NLR at admission to predict severe COVID-19 or mortality. Ordinal regression analysis was used to assess the impact of NLR on disease severity and mortality. RESULTS: Mean NLR was significantly higher in the severe COVID-19 group as compared to the mild/moderate group and in deceased as compared to discharged cases. ROC curve analysis revealed NLR to be an excellent predictor of disease severity as well as a prognostic parameter for risk of death. NLR was found to be a significant independent positive predictor for contracting the severe disease (Odd's ratio 1.396, 95% CI=1.112-1.753, p=0.004) and mortality (Odd's ratio 1.276, 95% CI=1.085-1.499, p=0.003). CONCLUSION: High NLR was significantly associated with the disease severity and mortality in COVID-19.

The Development of Ecchymosis after Administration of Convalescent Serum in a Patient with COVID-19 Associated with Thrombocytosis.

COVID-19 can have an unpredictable and severe course, leading to many hypotheses regarding its pathophysiology and clinical manifestations. Haematological manifestations are a significant predictor of disease severity. The most common observation is lymphopenia with an increased neutrophil:lymphocyte ratio. Platelets have been implicated in thrombogenic events, but the most frequently reported abnormality is mild thrombocytopenia. Here we present an interesting case of a patient with moderate COVID-19 who presented with cutaneous ecchymoses and thrombocytosis, and discuss this paradox. LEARNING POINTS: Bleeding manifestations such as ecchymoses can occur as an idiosyncratic reaction to the administration of convalescent plasma therapy in COVID-19.Thrombocytosis can occur in COVID-19 and could be a contributory factor to disease vasculopathy.

Glyphosate poisoning with acute pulmonary edema.

GlySH-surfactant herbicide (GlySH), one of the most commonly used herbicides worldwide, has been considered as minimally toxic to humans. However, clinical toxicologists occasionally encounter cases of severe systemic toxicity. The US Environmental Protection Agency (EPA) states that 'GlySH' is of relatively low oral and acute dermal toxicity. It does not have anticholinesterase effect and no organophosphate-like central nervous system (CNS) effects. The clinical features range from skin and throat irritation to hypotension and death. Severe GlySH-surfactant poisoning is manifested by gastroenteritis, respiratory disturbances, altered mental status, hypotension refractory to the treatment, renal failure, and shock.[1] GlySH intoxication has a case fatality rate 3.2-29.3%. Pulmonary toxicity and renal toxicity seem to be responsible for mortality. Metabolic acidosis, abnormal chest X-ray, arrhythmias, and elevated serum creatinine levels are useful prognostic factors for predicting GlySH mortality.[2] There is no antidote and the mainstay of treatment for systemic toxicity is decontamination and aggressive supportive therapy. We report a case of acute pulmonary edema, which is a rare but severe manifestation of oral GlySH poisoning, where patient survived with aggressive supportive therapy.

Sickle cell disease with recurrent priapism.

Sickle cell disease is a very common entity in central India, especially in Maharashtra. Patients usually present with recurrent haemolytic and/or vaso-occlusive crises. Although unusual, Priapism i.e. spontaneous painful erection of penis can be a debilitating manifestation of crisis. Especially when it occurs in prepubertal males it can lead to impotence in later life. It is also one of the least discussed complications of sickle cell disease. Here we present a case of sickle cell disease with recurrent priapism in a young boy of 16 years of age. He failed to respond to standard line of treatment. When all modalities failed he was given Tablet Gabapentin after which his priapism was totally relieved. We would like to recommend the use of Gabapentin in such cases of recurrent priapism.

Cerebrotendinous xanthomatosis: a rare genetic disorder.

A 32-year-old male patient presented with uncontrolled convulsions to the emergency room. He had epilepsy since childhood and was on tablet phenytoin sodium 100 mg three times a day. However, on detailed history elicitation and clinical examination, he was found to have a constellation of findings. He had multiple swellings over both the lower limbs and upper limbs at the site of various tendon insertions (xanthomas), mental retardation, speech disturbance, bilateral pyramidal tract involvement and bilateral cataracts. Based on clinical features, a diagnosis of cerebrotendinous xanthomatosis: a relatively rare genetic disorder was suspected, and later on confirmed histopathologically.