Thromboelastograph:A prognostic marker in sepsis with organ dysfunction without overt bleeding.

BACKGROUND: Coagulation abnormalities are not infrequent in sepsis. It is unclear if abnormalities in thromboelastogram (TEG) are associated with mortality in patients with severe sepsis without overt bleeding. MATERIALS AND METHODS: In this prospective study, patients were categorised as those with normal coagulation, hypercoagulable or hypercoagulable state based on admission TEG parameters (R time, K time, Maximum amplitude (MA), α angle). Their association with mortality was explored using Fisher's exact and Mann-Whitney U test as appropriate. RESULTS: The study cohort (n = 87; 49 male) with median (IQR) age 51 (42-60) years and admission SOFA score 8 (6-11) included scrub typhus (24.1%), pneumonia (22.6%) and urosepsis (10.3%). Non-invasive and invasive ventilation and vasopressors were required in 28.1%, 68.9% and 74%, respectively. Mortality was 24.1%. Based on R time, K time and α angle, 3.5% to 9.3% had a hypercoagulable state and 26.7 to 29.9% were hypocoagulable. Prolonged R time (p = 0.04) and reduced alpha angle (p = 0.01) in patients with hypocoagulable state was associated with mortality. K time, α angle and MA were significantly different in patients requiring transfusion (p < 0.001). CONCLUSION: A subset of patients with severe sepsis without overt bleeding are hypocoagulable. Hypocoagulability is associated with mortality and need for transfusion.

Tuberculous ARDS is associated with worse outcome when compared with non-tuberculous infectious ARDS.

BACKGROUND: Patients with tuberculosis (TB) developing acute respiratory distress syndrome (ARDS) may have a higher mortality when compared with ARDS of other infectious etiology. METHODOLOGY: In this single-centre retrospective cohort study spanning 5-years (2012 to 2016), TB-ARDS patients were age and gender matched (1:2) with non-TB infectious ARDS and followed up until death or hospital discharge. Clinical profile, treatment and outcomes were compared using t-test and Chi-square as appropriate. Mortality predictors were explored using Conditional Poisson regression analysis and expressed as relative risk (RR) with 95% confidence interval (CI). RESULTS: Of the 516 ARDS patients, 74 TB-ARDS and 148 non-TB infectious ARDS patients were included. Although admission APACHE-II (21.4 ± 7.1 vs. 17.6 ± 6.8, p < 0.001), incidence of shock (36.5% vs. 19.1%, p = 0.005) and mortality (59.5% vs. 29.7%, p < 0.001) were significantly higher in TB-ARDS than non-TB etiology, overall ICU length of stay and nosocomial infections were similar in both groups. On regression analysis, after adjusting for confounders, TB-ARDS (RR 1.82; 95% CI 1.13-2.92) and need for inotropes (RR 3.49; 95% CI 1.44-8.46) were independently associated with death. CONCLUSION: Patients with TB-ARDS presented sicker and had higher mortality when compared with ARDS due to non-TB infectious etiology.

Outcomes and factors influencing outcomes of critically ill HIV-positive patients in a tertiary care center in South India.

The incidence of (Human immune deficiency) HIV in India has fallen by 58% since the onset of the HIV epidemic. As of 2016 there are 2.1 million people living in India with HIV and only 49% of the adults with HIV are on ART (1). The HIV infected individuals may require intensive care due to various reasons. This study attempts to look at the outcomes of these patients admitted in the intensive care unit and the predictors of these outcomes. AIMS: 1. To assess the outcomes of critically ill HIV infected patients admitted in the medical intensive care unit. 2. Assessment of the factors that are likely to influence the outcome. MATERIALS AND METHODS: it is a retrospective medical review of all the patient records available on our electronic database. The study period was January 2008 - October 2013. RESULTS: in our study cohort the commonest reason for admission into the intensive care unit was sepsis associated with multi organ dysfunction (64%). A low CD 4 count, renal failure acute respiratory distress syndrome, and hypotension and multi organ dysfunction were predictive of a poor outcome in our study. CONCLUSION: The most common cause of admission of PLHIV in ours study cohort was Infections, ART associated side effects and low CD4 counts, presence of multi organ dysfunction, acute respiratory distress syndrome (ARDS), hypotension were associated with adverse outcomes.

Arterial thrombosis as primary presentation of endogenous Cushing's syndrome.

Cushing's syndrome is known to present with a characteristic set of clinical manifestations and complications, well described in literature. However, hypercoagulability remains an under recognised entity in Cushing's syndrome. A 31-year-old woman from Southern India presented with history of fever, left upper quadrant pain and progressive breathing difficulty for 3 weeks. Clinical examination revealed discriminatory features of Cushing's syndrome. Laboratory investigations showed biochemical features of endogenous ACTH-dependent Cushing's syndrome. Imaging of the abdomen revealed splenic collection, left-sided empyema and extensive arterial thrombosis. Gadolinium enhanced dynamic MRI of the pituitary gland revealed no evidence of an adenoma while a Ga-68 DOTATATE positron emission tomography CT scan ruled out an ectopic Cushing's. A diagnosis of endogenous Cushing's syndrome causing a prothrombotic state with extensive arterial thrombosis was made. She was initiated on oral anticoagulation and oral ketoconazole for medical adrenal suppression. She subsequently underwent bilateral adrenalectomy and was well at follow-up.

Cerebrovascular injury in cryptococcal meningitis.

Background Cryptococcal meningitis continues to be one of the common causes of chronic central nervous system infection worldwide. Individuals with cryptococcal meningitis can occasionally present with small vessel vasculitis causing infarcts primarily in the basal ganglia, internal capsule, and thalamus. Literature regarding patterns of cerebrovascular injury among patients with cryptococcal meningitis is scanty, and outcome following these vascular involvements is unknown. Aim To study the clinical profile, imaging findings, and details of vascular territory involved among patients admitted with cryptococcal meningitis and central nervous system infarct in a tertiary care center from India. And to compare the outcomes of patients of cryptococcal meningitis with or without central nervous system infarcts in terms of mortality and morbidity, Methodology A total of 151 patients with microbiologically proven cryptococcal meningitis over a time span of 11 years were retrospectively enrolled into the study. Of these, 66 patients met the inclusion criteria of having appropriate imaging of the brain. The presence of infarct in the imaging was analyzed by two independent radiologists. Patterns of central nervous system involvement and types of vascular injury were ascertained based on radiological parameters. Clinical parameters and outcomes of patients with and without infarcts were compared. Results Twenty (13%) of these patients had evidence of central nervous system infarcts on imaging. The mean age of patients with and without infarcts was 41 years and 38 years, respectively. Male predominance was present among both the groups. The presence of fever, neck stiffness, positive blood culture, and hydrocephalus in central nervous system imaging was similar among patients with or without infarct. Longer duration of illness, low sensorium at the time of presentation, low Glasgow Coma Scale score, presence of meningeal inflammation, cryptococcomas, and basal exudates in imaging were higher in patients with infarct. All the infarcts were of the lacunar type. Sixty percent of the cerebrovascular infarcts were acute in nature, 50% of these being multiple. Unilateral infarcts were seen in 70% of the patients. The most common site of infarct was the basal ganglia, others being distributed over the thalamus, frontal, temporal, parieto-occipital regions in the descending order. The presence of neurovascular involvement in the form of infarcts to the risk of morbidity and mortality had an odds ratio of 9.1 and 2.6, respectively. Conclusion Neurovascular involvement in chronic cryptococcal meningitis is a rare entity. These tend to present as multiple lacunar infarcts. Mortality and morbidity associated with these patients is higher when compared to patients who do not have infarcts. This result suggests that vascular injury plays a role in predicting outcome of patients with cryptococcal meningitis. Future studies are needed to understand the mechanism by which vascular events (infarcts) occur and result in poor outcome.

Varicella Zoster Virus Infection of the Central Nervous System - 10 Year Experience from a Tertiary Hospital in South India.

INTRODUCTION: Varicella zoster virus is an exclusively human neurotrophic virus. The primary infection with the virus causes varicella. The virus remains latent in nervous tissue and upon secondary activation causes a variety of syndromes involving the central nervous system (CNS) including meningoencephalitis and cerebellitis. MATERIALS AND METHODS: In this study, we looked at the epidemiology, clinical and laboratory features, and outcomes of patients who were admitted with varicella zoster of the CNS from 2005 to 2014. RESULTS: There were 17 patients. Fever was present in 13 patients, seizures in 9 patients and headache and vomiting in 4 patients each. A generalized varicella rash was present in 8 out of 17 patients. A single dermatomal herpes zoster was present in seven patients. Two patients had no rash. Varicella zoster polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) was done in 5 patients of which 4 were positive and 1 was negative. Nine patients had diabetes with an average glycated hemoglobin of 8.6%. Total number of deaths was five. CONCLUSIONS: Patients with diabetes who develop varicella or herpes zoster may be at risk for CNS complications. The diagnosis of varicella encephalitis has to rest on a combination of clinical findings and CSF PCR, as neither the rash nor the PCR is sensitive enough to diagnose all the cases with varicella encephalitis.

A rare case report of Strychnos nux-vomica poisoning with bradycardia.

Strychnine poisoning is a rare method of deliberate self-harm in adults. Poisoning with strychnine leaves is a rare form of strychnine poisoning, as the usual plant parts used are nuts, bark, and seeds. Although the common cardiac manifestations of strychnine positioning include tachycardia and hypertension, we report a patient with mild strychnine poisoning with bradycardia.

Low-dose methotrexate-induced acute interstitial pneumonitis: Report of two cases from South India and review of literature.

Methotrexate (MTX) is an antimetabolite used as a disease-modifying agent for various rheumatological conditions. We report two patients who were treated with daily low-dose MTX and developed acute interstitial pneumonitis requiring hospital admission. MTX-induced pneumonitis is a rare life-threatening side effect, high index of clinical suspicion is required, treatment is mainly withdrawal of MTX, supportive therapy, and adjunctive steroids, outcome is good if condition is recognized early, and appropriate treatment is given.