A unique case of fever with skin lesions.

The incidence of Nocardiosis was c.1-2 per 100,000 population worldwide in the early 2000s. Co-infection with Nocardia and MOTT (mycobacterium other than tuberculosis) is even more uncommon and has been described only in the setting of pulmonary manifestations in an immunocompromised (HIV) patient. However, over the last two decades, the incidence of Nocardiosis has increased to about 7-8 per 100,000 population, with pulmonary manifestations being the most common. With this background, we present the case of a middle-aged immunosuppressed man (post renal transplant with rejection), who presented with fever with extensive skin lesions and features suggestive of sepsis, without pulmonary involvement.

Understanding and Managing Autonomic Disorders in the Neurocritical Care Unit: A Comprehensive review.

Background: For a favorable outcome, patients admitted to critical care units require continuous monitoring and swift decision-making ability regarding management. One of the biggest challenges in neurocritical care units is the identification and management of autonomic dysfunction and in the worst-case scenario, autonomic storms. Objective: Most of the literature available focuses mainly on autonomic storms following traumatic brain injury. However, due to the myriad neurological presentations in a critical care setting, it is particularly important for physicians and intensivists to suspect and manage autonomic dysfunction in various neurological scenarios. Methods: Understanding the mechanism of paroxysmal sympathetic hyperactivity (PSH) is essential for early recognition and treatment. PSH-AM is an assessment measurement scale to diagnose and assess the severity of PSH in traumatic brain injury. However, this is not yet standardized across all neurological settings. Conclusion: We present a comprehensive report on understanding the mechanism of autonomic storms across various neurological disorders and outline the management.

Pictorial Essay of Cervical Duplex Ultrasonography.

Objectives: Cervical duplex ultrasonography (CDU) is a simple, non-invasive, portable technique, that provides valuable high-quality visual information about the integrity of the carotid and vertebral vessels, plaque morphology and flow hemodynamics. CDU is useful in the assessment and follow up of patients with cerebrovascular disease as well as other conditions like inflammatory vasculitis, carotid artery dissection and carotid body tumours. CDU is inexpensive and invaluable in smaller centres. Methods: CDU was performed in all patients in both longitudinal and transverse planes in the out-patient clinic. Brightness mode (B-mode) and Doppler waveforms were obtained. Relevant findings were presented. Results: CDU provides real time visualisation of plaque characteristics and follow up, hemodynamic characteristics in Takayasu arteritis, visualisation of dissection. Conclusion: With availability of MR/CT angiography, CDU can be an adjuvant in follow up, triage and early bed-side diagnosis of the vascular diseases. We present our experience with CDU in the out-patient clinics in this pictorial essay.

Analysis of an outbreak of nosocomial COVID-19 at a tertiary care centre in South India.

BACKGROUND: Nosocomial outbreaks of COVID-19 have been reported sporadically since the beginning of the COVID-19 pandemic. We sought to study the transmission dynamics in a nosocomial COVID-19 outbreak in our centre. METHODS: This was a retrospective cohort study in a 500 bedded tertiary care hospital in South India. Inpatients who were suspected to have likely or definite hospital-acquired COVID-19 and hospital staff members who were found to be COVID-19 positive during the same time frame were studied and the likely transmission dynamics described. RESULTS: During the study period, 173 patients were diagnosed to have COVID-19, out of which, 15 (8.6%) patients who fulfilled the criteria for likely or definitely hospital-acquired COVID-19 infection were identified from six different wards. During the same period, 121 hospital staff members were diagnosed with COVID-19. Out of these, 18 (14.9%) hospital staff members were identified who could have been the potential source of infection for these 15 patients based on the overlap of location of the staff and the patients, and their infectivity windows. Direct contact and fomite transmission were likely the predominant driver of transmission in our study as there was use of universal face masks and face shields. CONCLUSION: Despite the admission of a large number of COVID-19 patients and a relatively large proportion of hospital staff members who tested positive for the disease, the proportion of nosocomial COVID-19 in our centre remained low. A policy of universal gloving, coupled with the already existing practice of universal N95 masking and face shield use, could potentially bring down the rate of nosocomial COVID-19 even further.

MRI outcomes in patients with acute-onset vertigo in the emergency department - A prospective study.

INTRODUCTION: Vertigo is an abnormal sensation of motion which arises due to a mismatch between various sensory modalities involved in maintaining balance. Vertigo can be due to central or peripheral causes and intensely debilitating for some patients. Acute onset vertigo is defined as the commencement of vertigo within 24 h. This can present with a variety of overlapping symptoms, making it difficult to distinguish central from peripheral causes. In the emergency setting, mis-diagnosing acute onset vertigo as benign may have serious implications. METHODS: This prospective study included consecutive patients presenting to our Emergency Department with acute vertigo between March 2019 and March 2020. We aimed to evaluate and validate the utility of magnetic resonance imaging (MRI) of the brain among patients with acute onset vertigo. RESULTS: A total of 70 patients with acute onset vertigo were recruited. MRI of the brain revealed acute changes in 23 (32.9%) out of the 70 patients included in the study. Even among the 29 (41.4%) patients who presented with isolated vertigo without any other clinical signs, MRI of the brain showed acute changes in 3 (10.3%) of them. CONCLUSION: MRI is a useful tool in diagnosing and differentiating peripheral from a central cause of vertigo. It avoids misdiagnosis in the emergency setting and facilitates early administration of appropriate treatment.

Neurological Complications with COVID-19: A Contemporaneous Review.

The COVID-19 pandemic is raging across the world, affecting 212 Countries and Territories around the world. It has infected more than 3.7 million people with a mortality rate of around 7%. Although the causative virus, the SARS-CoV-2 is primarily a respiratory pathogen, recent observational studies have documented a high rate of neurological complications associated with COVID-19. We searched PubMed databases from December 01, 2019 to June 9, 2020 for articles published on "COVID 19" OR "coronavirus" with targeted search words. We also search preprint servers for neurological complications of COVID-19. Neurological manifestations are seen in around 36%-45% of patients with COVID-19 and can involve almost every part of the central nervous system (CNS) from the hemispheres, cranial or peripheral nerves, spinal cord, and muscle. The mechanisms vary from direct viral invasion of the CNS, to a dysregulated host immune response to molecular mimicry to multiorgan dysfunction. In many patients, neurological manifestations preceded other systemic features or the diagnosis of COVID-19. Sick patients with COVID-19 will require ICU care and many patients may present first to the neurocritical care ICU and receive a diagnosis of COVID-19 later. Hence, it is important for all healthcare personnel to be aware of the myriad neurological manifestations of this infection, so as to initiate appropriate infection control practices and refine investigation and treatment protocols.

Lessons of the month: Herpetic viral dermatomyositis.

We present the case of a man who presented with severe left lower back pain radiating to the anterior aspect of left thigh. He also had fever and headache. Due to the exquisite tenderness along the inguinal region, the possibility of a psoas abscess was considered. Magnetic resonance imaging of the spine and thigh were performed. These revealed left psoas muscle abnormalities suggestive of an evolving myositis or abscess. However, the next day, he displayed florid rashes in the left L2-L3 dermatomes consistent with herpes zoster. The clinical manifestations of herpes zoster include neuralgic pain and dermatomal skin rashes. It also presents with a prodrome of fever, headache, myalgia, myositis and Guillain-Barré syndrome. In a developing embryo, somites split to form dermatomes, myotomes (skeletal muscles), syndetomes (tendons and cartilage) and sclerotomes (bones). Our case illustrates that herpes zoster can involve the so called 'dermomyotome', a combination of the dermatome and myotome and result in a localised dermatomyositis.

A Hot Body in a Cold Room Hyperthermia Secondary to Rapid Diuresis in Cardiac Failure; the Perils of Rapid Fluid Shifts.

A 66-year-old man was admitted with anasarca and congestive cardiac failure. He was started on intravenous diuretics and fluid restriction and lost nearly 35 kg of fluids in 13 days. He then developed hyperthermia and delirium. An extensive workup was inconclusive. Analysis of his inpatient fluid balance chart revealed the chance association of massive fluid loss and hyperthermia. Rapid diuresis-induced hyperthermia and volume contraction were considered, and his fluid balance was adjusted. Within 2 days, his temperature normalized and he regained consciousness. Hyperthermia and its causative mechanism are discussed in this article.