Multiorgan Inflammatory Syndrome in Adults MIS-A Post SARS-CoV-2 Infection: A Novel Clinical Enigma.

BACKGROUND: Multisystem inflammatory syndrome in adults (MIS-A) is an emergent heterogenous clinical syndrome seen in the convalescent phase of COVID-19 infection. MIS in children (MIS-C) is a rare but severe post-COVID-19 illness that has been recognized by the WHO and the Centre for Disease Control and Prevention (CDC). It introduced a similar illness in adults based on multiple case series, identified as MIS-A. OBJECTIVE: We present four rare cases of multiorgan inflammatory syndrome in adults (MI-A) presented in Goa Medical College (Tertiary Medical Institute). We would like to highlight the diversity of presentation of symptoms with a significant history of previous covid infection, laboratory abnormalities, the clinical course of the disease, treatment strategies, and response and follow-up findings. We seek to highlight the emergence of a serious clinical entity that can be fatal if not diagnosed or treated promptly. MATERIALS AND METHODS: This was a descriptive study conducted in Goa Medical College from June 2021 to November 2021. A systematic search in the Department of General Medicine, the Department of Medical Records, and data from ICU, ITU, and critical covid wards were collected. RESULTS AND CONCLUSION: A total of four cases fulfilling the criteria for MIS-A as per MMWR (CDC 2020)were included, ranging from the age group of 29-70 years. All had features of severe systemic inflammatory response with multiple organ dysfunction and elevated proinflammatory markers. All four patients had a recent history of (mild) COVID-19 infection. Hence, in the current pandemic scenario, MIS-A should be considered as a possible diagnosis in patients with recent COVID infection presenting with MODS, when the obvious septic cause is excluded through thorough clinical, physical, serological, laboratory, and radiological investigations. However, the presence of a past covid infection may not be an absolute criterion due to mild symptoms of the primary covid infection which usually go unnoticed resulting in nontesting.

Clinical Spectrum of Henoch Schonlein Purpura in Adults: A Hospital Based Study.

BACKGROUND AND OBJECTIVES: Henoch Schonlein purpura (HSP) is a small vessel vasculitic disorder common in children and has been extensively studied. Although it is known to also occur in adults there is relative paucity of data as regards to its clinical spectrum, complications and outcome, particularly in Indian context. Hence the study was undertaken with the objective to evaluate the various skin manifestations, systemic complications of HSP in adults and also compare it with data available in children in various published clinical studies.Study design, materials, methods : In this retrospective, observational, hospital-based cohort study conducted at Goa Medical College the premier teaching institute from Goa, clinical data of adult patients (>18 years age) fulfilling the diagnostic criteria as per European League Against Rheumatism (EULAR) 2010 criteria for HSP was obtained, over period of 6 years. All the clinical manifestations, complications, investigations, outcomes were recorded. Skin biopsy histopathology and immunofluorescent test findings were also obtained. The data was analysed and results were compared to the data available in pediatric studies to ascertain the similarities and differences. RESULTS: In our study cohort of 30 patients, we found a higher incidence of atypical and more extensive skin lesions particularly bullae (40%), necrotic ulcers (53.3%), urticarial wheals (53%) unlike in children as well as differences in distribution especially sparing of buttocks in adults. The incidence of gastrointestinal involvement was 80% which was higher than that reported by other studies in adults (35% to 70%). A significant 40% of patients had upper GI bleeding with endoscopy revealing small hemorrhages in gastric mucosa. Lower GIT bleed was seen in 8 patients. Renal involvement (microscopic hematuria, overt glomerulonephritis, nephrotic syndrome) was seen in 65% patients which was higher than that reported in children (43 %). Skin biopsy immunofluorescence was found to be positive in almost 66 % cases confirming IgA deposition which is the hallmark pathological finding. CONCLUSIONS: HSP, though less common in adults than children, presents with atypical and more severe cutaneous manifestations like bullae, necrotic ulcers, urticarial wheals. Systemic involvement appears to be more frequent and causing more morbidity and mortality as compared to the data in children mentioned in standard literature and most of the patients required steroid therapy for treatment unlike in children where majority of these cases are self-limiting. Skin involvement does not necessarily mirror gastrointestinal involvement in terms of severity and temporal occurrence.

Clinical Spectrum and Complications of Polycythemia, in Patients presenting at Tertiary Care Centre at Goa.

BACKGROUND: Polycythemia is characterized by rise in hemoglobin and hematocrit, either as a result of hematopoietic clonal expansion (Vera) or secondary to hypoxic stimuli (secondary polycythemia).It is of great importance to detect early and identify the type of polycythemia and also asses the thrombotic risk so that timely and appropriate treatment can be given. The present study aims to characterize the different presentations and complications of polycythemia, evaluate genetic factors and differences between the two categories of polycythemia in ethnic Goan subjects. AIMS AND OBJECTIVES: 1. To identify common presentations and etiologies of polycythemia 2. To evaluate and compare the differences in clinical features, hematological parameters and complications of polycythemia in primary (vera) and secondary polycythemia 3. To study the profile of JAK 2 V617F mutation in Goan patients with polycythemia Vera. MATERIALS AND METHODS: This was a retrospective observational cohort study, conducted at the Department of Internal Medicine, Goa Medical College, a tertiary care, teaching institute in the state of Goa. We analysed clinical and laboratory data of patients of polycythemia due to all causes (polycythemia Vera and secondary causes) previously admitted or following up at the hospital from January 2014 to December 2017. In each of these 2 groups, we studied the various clinical parameters including the age at presentation,sex,residence, symptomatology and clinical findings,presence of hypertension, as well as complications arising due to polycythemia (past and at present) hematological data including Hb,HCT, total WBC count, absolute neutrophil count, RBC and platelet count, ESR, rouleaux formation, EPO levels and JAK 2 V617F mutation analysis (done by real time PCR technique) and requirement of phlebotomies in the last 4 years. Commonest clinical presentations and complications arising due to polycythemia, in each group were analysed and compared. RESULTS: A total of 44 patients were included in the study out of which 33 were males. Polycythemia Vera was seen in 43.18% while secondary causes were seen in 56.8 % patients. Patients with Vera were found to be more symptomatic with higher levels of mean Hb, HCT, cell counts and with a higher requirement of phlebotomy and more thrombotic complications. Amongst Vera group, patients having high WBC count, increased Rouleau formation, and JAK2 positivity were found to be more prone for thrombosis. Hypertension was frequently seen to be associated with both groups. Obstructive sleep apnea followed by COPD was found to be the commonest causes of secondary polycythemia. CONCLUSION: Our study revealed that patients with polycythemia Vera are more symptomatic and have a higher requirement of phlebotomy and a higher thrombotic tendency (arterial being more common than venous) as compared to the secondary polycythemia owing to a higher hyperviscocity in the former. Leukocytosis and JAK 2 617F positivity were found to be important predictors of thrombotic risk. Hypertension was found to be frequently associated with Vera as well as in secondary causes due to OSA.

Scrub typhus in patients reporting with acute febrile illness at a tertiary health care institution in Goa.

BACKGROUND & OBJECTIVES: Scrub typhus is one of the differential diagnoses of haemorrhagic fevers especially if associated with jaundice and/or renal failure. Goa State in the western region of India has been witnessing increased incidence of such fevers, therefore, the present study was undertaken to identify whether scrub typhus is the aetiological agent. METHODS: Adult patients presenting with undiagnosed febrile illness between June 2009 to October 2010, were evaluated. Testing was done using a commercial ELISA kit for specific IgM antibodies against Orientia tsutsugamushi. RESULTS: Of the 44 patients included in the study, 15 (34%) were found to be positive for IGM antibodies against O. tsutsugamushi. The cases were seen mainly in the months between July to November. The common symptoms noted were fever, myalgias, gastrointestinal complaints, followed by breathlessness, rash and jaundice. The pathognomonic features such as eschar and lymphadenopathy were seen only in two patients. Nearly two third of the patients had leukocytosis (67%) and low serum albumin (60%). The most common complication noticed was hepatitis (80%) followed by acute respiratory distress syndrome (ARDS) (60%), thrombocytopenia (40%) and acute renal failure (33%). Five patients died in the course of illness. INTERPRETATION & CONCLUSIONS: Our results showed that scrub typhus should be considered in the differential diagnosis of acute febrile illness associated with gastrointestinal symptoms, rash, myalgia , including those with organ dysfunctions such as hepatorenal syndrome, coagulopathy or ARDS. Empirical treatment with doxycycline or macrolides may be given in cases with strong suspicion of scrub typhus.

Diabetic Tongue - Could it be a Diagnostic Criterion?

Diabetes mellitus (DM) is a common disease which usually manifests in the form of polyuria, polydipsia, weight loss, fatigue, weakness, blurry vision, frequent skin infections, and slow healing of skin lesions. Taste disturbances like ageusia, hypogeusia and dysgeusia have been associated with DM. The early diagnosis of DM based on these symptoms is very important to start treatment early and thereby prevent complications. We present an interesting case of a female presenting with altered taste as the first symptom of DM.