Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Background & objectives: Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR). Methods: A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests. Results: Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days. Interpretation & conclusions: With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.

Brain abscess in patients with chronic kidney disease: A case-based approach to management in resource-limited settings.

The management of patients with brain abscess poses a significant challenge to clinicians in patients with chronic kidney disease. Obtaining a biopsy sample from the affected area is the mainstay in the diagnosis, but it is often unavailable. In most cases, therapy is guided by clinical findings and imaging alone. We discuss three cases of brain abscess- each with a different scenario and discuss the issues faced in management. The first case was a 32-year-old post-renal transplant male patient with a brain abscess due to dematiaceous fungi and was treated with amphotericin. The second case was a 42-year-old female patient with stage 5 chronic kidney disease on maintenance hemodialysis who presented with a brain abscess due to suspected fungal infection based on imaging findings and was managed with antibiotics and voriconazole. The third case was a 42-year-old post-renal transplant male patient who presented with a brain abscess due to nocardiosis and was managed with cotrimoxazole, meropenem and linezolid. We also summarize the approach to the management of brain abscess in resource-limited settings.

Recurrent chylous effusions and venous thrombosis: Uncommon presentation of a common condition.

Spontaneous bilateral chylothorax and chylous ascites rarely develop in conjunction with systemic venous thrombosis, and the most common cause of non-traumatic chylous effusion is a malignancy. A 23-year-old immunocompetent female presented with a fever of 5 months' duration associated with progressive shortness of breath and abdominal distension. Evaluation revealed bilateral chylothorax, chylous ascites, and multiple venous thrombosis. Anti-tubercular drugs were initiated on the basis of a lymph node biopsy and computed tomography findings, but her symptoms worsened, and she developed massive bilateral pleural effusions with type 2 respiratory failure requiring invasive mechanical ventilation. She was managed with anti-tubercular drugs, chest tube drainage, octreotide, anticoagulants, and other supportive treatments. A multipronged approach to the management of chylous effusions and addition of octreotide led to resolution of symptoms. The challenges faced in diagnosing and managing this case are discussed in this report.

A Catastrophic Presentation of Enteric Fever with Secondary Hemophagocytic Lymphohistiocytosis.

A 19 year old boy presented to the emergency room with fever of one week duration along with bleeding manifestations, few gastrointestinal symptoms, tachycardia, tachypnea and subtle encephalitic features. He was worked up for the usual causes of short duration fever, which proved inconclusive. In view of clinical worsening and cytopenias, a careful investigation process helped us in ruling out common etiologies for such a fever, alongwith unearthing the possibility of an underlying secondary hemophagocytic lymphohistiocytosis which led to severe thrombocytopenia and persistent high grade pyrexia. Widal test was positive in high titres, and patient was continued with antibiotics. Prompt treatment led to the uneventful recovery of the patient without any sequelae. Bleeding manifestations subsided, patient had rapid clinical improvement and was discharged after completing the course of antibiotics.