Clinical Profile and Outcome of Patients presenting with Guillain - Barré Syndrome in a Medical Intensive Care Unit of a Tertiary Care Hospital.

BACKGROUND: Guillain-Barré syndrome (GBS) is an inflammatory, autoimmune disorder of the peripheral nervous system that is acute in onset, self-limited, and can result in significant morbidity, placing a burden on the healthcare system. This study aims to study the clinical profile and outcome of patients with GBS who require intensive care unit (ICU) and mechanical ventilation (MV). MATERIALS AND METHODS: After Institutional Ethics Committee approval, a single-center, prospective, observational study was conducted, recruiting 51 patients from the medical ICU with GBS over 18 months. Patients were categorized into three groups as per the timing of the commencement of immunomodulator therapy. The association between dependent variables like the need for MV, patient outcome, and independent factors like time of initiation of immunomodulator therapy from the time of onset of symptoms and age-groups; were analyzed using the Chi-squared test and the overall disability sum score (ODSS) with Spearman's rank correlation test. RESULTS: Out of 51 patients in the study, (52.94%) were male, with a male:female ratio of 1.12:1. Most of them had quadriparesis (98.04%) or bulbar symptoms (56.86%). A total of 24 (47.05%) patients required MV. The presence of bulbar weakness at admission had a statistically significant positive correlation with the need for MV (Spearman's ρ = 0.663, p = 0.001), the need for prolonged MV (Spearman's ρ = 0.457, p = 0.001), duration of MV (Spearman's ρ = 0.512, p = 0.001) and duration of ICU stay (Spearman's ρ = 0.516, p = 0.001); and a negative correlation with improvement in ODSS (Spearman's ρ = -0.409, p = 0.001). Early commencement of immunomodulator therapy was associated with a significantly decreased probability of requiring ventilatory support (p = 0.001), decreased probability of requiring prolonged MV (p = 0.04), and a decreased duration of ICU stay (p = 0.004). CONCLUSION: Early commencement of immunomodulator therapy decreased the probability of requiring ventilatory support and improved the outcome. Breathlessness and bulbar symptoms at admission were poor prognostic indicators in terms of the need for MV and the duration of both the ICU stay and MV.

Evaluation of the Safety and Efficacy of Favipiravir in Adult Indian Patients with Mild-to-Moderate COVID-19 in a Real-World Setting.

Purpose: To evaluate the safety and efficacy of favipiravir, which is prescribed for the treatment of patients with mild-to-moderate coronavirus disease 2019 (COVID-19) in India. Patients and Methods: This was a prospective, open-label, multicenter, single-arm postmarketing study conducted in India. Patients with mild-to-moderate COVID-19 received favipiravir (3600 mg [1800 mg orally twice daily] on the first day, followed by 800 mg orally twice daily, up to a maximum of 14 days) as a part of their treatment. The primary endpoints were to evaluate the safety of favipiravir by assessing the number of adverse events (AEs) and treatment-related AEs. The secondary endpoints were to evaluate the efficacy of favipiravir by assessing time to clinical cure, rate of clinical cure, time to pyrexia resolution, rate of oxygen requirement, and all-cause mortality. Results: A total of 1083 patients were enrolled in this study from December 2020 to June 2021. Adverse events were reported in 129 patients (11.9%), 116 (10.7%) of whom had mild AEs. Dose modification or withdrawal of favipiravir treatment was reported in four patients (0.37%). The median time to clinical cure and pyrexia resolution was 7 and 4 days, respectively. A total of 1036 patients (95.8%) exhibited clinical cure by day 14. Oxygen support was required by 15 patients (1.4%). One death was reported, which was unrelated to favipiravir. Conclusion: In the real-world setting, favipiravir was well-tolerated, and no new safety signals were detected.

Study of Clinical Spectrum of Severe COVID-19 Infection in Elderly Patients and its Outcome-A Major Mumbai Tertiary Care Hospital Observations.

BACKGROUND: At 140 million, India has the second largest population of old people in the world, as per the 2011 census.1 The covid 19 pandemic has wreaked havoc in millions of lives. Elderly are especially vulnerable to COVID-19 and experience high morbidity and mortality as a result of immunosenescence. Age is independently linked with mortality, but age alone does not adequately capture the robustness of older adults who are a heterogeneous group. The current research was done in a tertiary healthcare hospital in Maharashtra to understand the clinical profile and factors that affected the outcome of elderly during the second wave of the COVID pandemic. METHOD: This was a single centre retrospective observational study done in a tertiary hospital which was admitting both covid and non-covid patients during the time of this study. All elderly patients admitted with COVID 19 disease in Covid ward and covid ICU (Intensive care unit) were included in the study. Their Demographic details, duration of illness, vital parameters, oxygen saturation, partial pressure of arterial oxygen compared to fraction of inspired oxygen (PaO2-FiO2 ratio) were recorded and also relevant investigations such as complete blood count, kidney function tests, liver function tests, arterial blood gases, chest X-rayand ECG (Electrocardiogram),CT scan of the brain, CSF(cerebrospinal fluid) studies and other tests where relevant were recorded. Inflammatory markers such as C-Reactive Protein (CRP), Ferritin, D-Dimer and Chest CT scan were noted. Clinical profiles and outcomes were noted till discharge or death. RESULTS: Among 231 patients that were included in this study, 81(35%) were female and 150 (65%) were male. Ninety-two patients died (39.8%) while 139 patients (60.2%) survived in our study. Majority of our patients (211;91.3%) presented in category E(pneumonia with respiratory failure) or category F(pneumonia with respiratory failure and multiorgan dysfunction syndrome). Factors which had a major impact on mortality were- a low PaO2-FiO2 ratio on admission, high C-Reactive Protein (CRP) levels, high d-dimer levels, a finding of bilateral ground glass opacities on x-ray, and need for invasive ventilation on admission. CONCLUSIONS: Elderly remain vulnerable to severe consequences of COVID-19 infection owing to the increasing comorbidities and immunosenescence in them. Prolonged oxygen therapy and intensive respiratory rehabilitation are the mainstays of effective management. Given the constant threat of mutating virus, masking, maintaining hand sanitization, vaccination and also caring for our elders while still maintaining social distance are our best bet against a fatal third wave.

Predictors of Outcome in Acute Respiratory Distress Syndrome in Acute Febrile Illness in Medical Intensive Care Unit.

AIMS: Acute Respiratory Distress Syndrome (ARDS) is a known complication of acute febrile illness (AFI). The in-hospital mortality rate of ARDS is between 35-44%. Our study aimed to identify the different parameters that could be used to detect patients at higher risk of poor outcome in AFI complicated by ARDS. METHODS: 130 patients with AFI complicated by ARDS as per Berlin definition, admitted at the Medical Intensive Care Unit of Seth GS Medical College KEM Hospital Mumbai, were studied over a period of 18 months. Investigations done during the course of MICU stay were noted. From the reports, SOFA score, delta SOFA score, Lung Injury Score (LIS), Disseminated Intravascular Coagulation (DIC) score (by ISTH scoring system) were also calculated. Main outcome was recorded as transfer out from the MICU or death. RESULTS: Etiology of the 130 patients of AFI with ARDS was as follows-dengue 32 patients (24.6%), H1N1 -31(23.8%), undifferentiated fever -30 (23.1%), leptospirosis-22 (16.9%), malaria-15 (11.5%). Our study had a mortality rate of 25.4 %( n=33). 40.8% of the study population required invasive ventilation at admission. SOFA score at admission and 48 hours, delta SOFA score, PaO2/ FiO2 ratio at admission and 48 hours, Blood Urea Nitrogen (BUN), creatinine, bicarbonate and albumin were the significant predictors of overall outcome. Hemoglobin, platelets and leukocyte counts, pH, pO2 , pCO2 at admission and 48 hours, Lung Injury Score (LIS) and DIC score were not significant predictors of outcome. CONCLUSION: SOFA score at admission and 48 hours, delta SOFA score and PaO2 / FiO2 ratio were significant predictors of outcome in patients of acute febrile illness with ARDS. LIS and DIC score were not significant predictors of outcome.

COVID-19 Associated Stroke-A Single Centre Experience.

BACKGROUND AND PURPOSE: Various neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020. METHODS: We recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes. RESULTS: There were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17-91; F/M=20/38; 24% (14/58) aged ≤40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). 'Early stroke' (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low Glasgow coma score (GCS) and requirement for increasing intensity of respiratory support predicted in-hospital mortality. CONCLUSIONS: We had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission.

Factors Affecting Maternal Outcome in Urban Setting (FAMOUS)-ICU Experience.

BACKGROUND: Pregnant women in India are at higher risk of dying as compared to middle to high income countries. Deaths can be prevented if risk factors are identified, critical illness is diagnosed early and timely care is provided. The present research was undertaken to study the clinical profile and factors affecting the outcome of pregnant and postpartum patients in the Medical Intensive Care Unit (MICU). METHOD: A total of 75 consecutive patients of age >18 years with confirmed pregnancy or postpartum females within 42 days from date of delivery requiring admission in ICU for at least one organ dysfunction as per APACHE II criteria1 were enrolled in the study. Clinical profiles of patients and outcomes were measured till hospital discharge. RESULTS: Among 75 patients, 18(24%) patients were postpartum while 57(76%) were antepartum.The commonest symptom was fever (64%), followed by breathlessness (62.7%). Respiratory distress (58.7%) was the commonest indication for transfer to MICU. While 60(80%) patients were admitted for medical illnesses in pregnancy, 15(20%) patients were admitted for obstetric complications. Acute infections including malaria, dengue and leptospirosis were the commonest illness diagnosed in 19(25.3%) patients. Severity of illness measured using APACHE II score varied from 4 to 35 points with a mean score of 10.61.Longer duration of symptoms before seeking medical attention, lower pH, lower paO2/FiO2 ratio and serum bicarbonate, a diagnosis of tuberculosis and a higher APACHE II score were associated with a higher mortality. CONCLUSION: With institution of intensive therapy in critically ill maternal patients, 80% of patients could be saved and 61% of fetuses had uneventful outcomes.The prognosis was better for obstetric illnesses than for medical illnesses with only 3 patients dying of obstetric causes whereas 12 patients died of medical illnesses common to the general population. Even though APACHE II score was higher in the group with obstetric conditions (mean=11 vs. 8.1), the mortality was lower.

Leptospirosis in Intensive Care Unit.

Tropical infections constitute 20 - 30% of intensive care unit (ICU) admissions in developing countries. Leptospirosis is a spectrum with mild form presenting as an acute febrile illness with jaundice, complicating in few as acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and multi-organ dysfunction syndrome (MODS). The poor prognostic markers are hemorrhagic ARDS, acute renal failure, DIC, severe metabolic acidosis, older age, chronic alcohol abuse, high SOFA score, and septic shock. The confirmatory diagnosis relies on antibody testing, such as microscopic agglutination test (MAT) and IgM ELISA, while the reverse transcription-polymerase chain reaction test being reserved for clinically suspected antibody negative cases. The spectrum of multi-organ involvement necessitates a complete hematological, biochemical workup, including electrocardiogram (ECG), chest X-ray, and two-dimensional echocardiography. Specific antimicrobial therapy consists of the following-benzylpenicillin, ceftriaxone, cefotaxime, and doxycycline. The reported mortality ranges from 6% to as high as 44%. Various ICU scores like SPiRO, THAI LEPTO score, and Faine's criteria have been useful in risk stratification. Optimizing intensive care treatment with appropriate antibiotics, lung protection ventilation strategies, strict fluid management, and if need be timely initiation of renal replacement therapy (RRT) helps in reducing mortality. How to cite this article: Karnik ND, Patankar AS. Leptospirosis in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2): S134-S137.

A Study of the Outcome of Critically Ill Elderly Patients in a Tertiary Care Hospital Using SOFA Score.

BACKGROUND: With a rapidly rising geriatric population, the magnitude of elderly patients requiring intensive care is a major cause of concern. Data on critically ill geriatric patients is scarce, especially in developing countries. AIM AND OBJECTIVE: The aim of the study is to identify the etiology, clinical profile, and outcome in elderly patients admitted to the intensive care unit (ICU) and to predict their survival using the sequential organ failure assessment (SOFA) score. MATERIALS AND METHODS: A prospective observational study was performed over a period of 18 months with analysis of 100 patients admitted to the ICU, above the age of 60 years, with multi-organ dysfunction. The outcome of discharge or death was studied using the SOFA score on admission, on day 2, and the delta SOFA score. RESULTS: In this study of 100 patients, 88% of patients were in the 60-70 years age-group. The number of male and female patients was equal. Seventy percent of patients had comorbidities, of which hypertension was most common. The two most common etiologies were acute febrile illness and pneumonia. The use of mechanical ventilation, inotropic support, and serum creatinine has a significant association with the outcome. The SOFA score at admission did not have a significant association, but the score at 48 hours and delta SOFA score co-related with the outcome of the patients. Sixty-four patients got discharged; thus, there was a survival rate of 64%. CONCLUSION: The SOFA score at 48 hours is the most sensitive predictor of outcome, followed closely by the delta SOFA score, as compared to the SOFA score on admission, for critically ill elderly patients. There is a significant association of use of mechanical ventilation, inotropic support, and serum creatinine with the outcome. HOW TO CITE THIS ARTICLE: Chopra S, Pednekar S, Karnik ND, Londhe C, Pandey D. A Study of the Outcome of Critically Ill Elderly Patients in a Tertiary Care Hospital Using SOFA Score. Indian J Crit Care Med 2021;25(6):655-659.

Transfemoral thrombolysis with thrombosuction: an aid to renal biopsy in a case of acute Budd Chiari syndrome complicating nephrotic syndrome.

Renal biopsy is usually a prerequisite in the diagnosis of adult patients with nephrotic syndrome. Acute Budd Chiari syndrome is a known complication of certain aetiologies of nephrotic syndrome like membranous glomerulopathy and minimal change disease. This complication requires emergent anticoagulation, which would preclude the performance of a renal biopsy. We report the case of a 47-year-old woman who presented with acute Budd Chiari syndrome as the initial presentation of nephrotic syndrome. The difficult situation in which we had to give anticoagulation and also perform a renal biopsy led us to devise a novel way to treat the patient, namely, the initial use of transfemoral thrombolysis and thrombosuction followed by a renal biopsy, which confirmed the diagnosis of primary membranous nephropathy. Anticoagulation was safely instituted 48 hours later with documented clinical and radiological improvement.

Dermatomyositis during COVID-19 Pandemic (A Case Series): Is there a Cause Effect Relationship?

Viruses have been shown to modify the clinical picture of several autoimmune diseases, including type 1 diabetes, systemic lupus erythematosus (SLE), rheumatoid arthritis and multiple sclerosis. Viral infections have also been considered as a possible trigger for autoimmune disorders like myositis through myositis specific antibodies. Dermatomyositis is an acquired inflammatory myopathy which is relatively rare with incidence of 9.3 per 1 million persons. Usually we come across 1-2 patients of dermatomyositis per year, amongst 800-1000 new patients in our tertiary care rheumatology services. A surge in the incidence was noted this year during the months of April-August of 2020, the period coinciding with the occurrence of corona virus (COVID-19) pandemic in the city of Mumbai, the total number of cases encountered being five in a span of six months. The following case series includes five such cases with review of available literature on virus-triggered autoimmunity with special reference to SARS-CoV-2 and the challenges of immunosuppression during this pandemic.

Impaired NK cell activation during acute dengue virus infection: A contributing factor to disease severity.

Dengue viral (DENV) infection has a broad clinical spectrum ranging from classical febrile illness to life-threatening disease. Literature suggests that spectrum of illness could be due to differences in innate immune-responses; however, the knowledge is still at infancy. Amongst the various cells involved in innate immune responses, NK cells play a central role, particularly in anti-viral immunity. Thus in this study we have evaluated the role of NK-cells during acute-DENV infection and its influence on severity of disease, by analyzing activation, cytotoxic receptors, cytolytic granule contents and degranulation markers on NK-cells during different stages of infection. Based on the clinical manifestations and severity of the disease, DENV patients were classified into patients with dengue without warning signs (DF), dengue with warning signs (DFWS) and severe dengue (SD) patients. During acute-DENV infection, though there was no alteration in frequency of NK-cells, significant increase in frequency of CD56bright subset in DF patients (p < 0.05) was observed, while it remained unaltered in SD patients. We also found that, CD56dim NK-cell subset of DF patients had elevated CD69 expression, granzyme B and intracellular IFN-γ levels compared to SD patients (p < 0.05). Amongst the NK-cell cytotoxicity receptor (NCR), NKp30 receptor was significantly elevated in DF patients (p < 0.05), however in SD patients it was comparable to healthy controls. This receptor is essential for dendritic cells-NK-cells crosstalk for initiating adaptive immune response. IL-15 is known to induce NKp30 expression, which was also seen to be elevated in DF patients (p < 0.05) but unaltered in SD patients. In SD patients, even post-6 days of infection i.e. during recovery phase, CD69 and NKp30 expression did not raise, suggesting impaired NK-cell response in these patients. To summarize, our study reports, that efficient NK cell response during acute phase of DENV infection is crucial for preventing severity of the disease. This study helps in understanding the dynamics of NK cell response in immunopathogenesis of DENV infection; which is crucial for development of efficacious therapeutics as well as vaccine.

Impact of COVID-19 on maintenance haemodialysis patients: The Indian scenario.

There is a lack of data describing the impact of the novel coronavirus 19 pandemic on the patients of chronic kidney disease stage V-dialysis (CKD V-D) from resource-limited countries. A growing body of literature describes an increased susceptibility of CKD V-D to COVID-19 with adverse outcomes in those with severe disease. In the current retrospective report, we elucidate the outcome in consecutive 37 CKD V-D patients with COVID-19 from two dialysis centres in Mumbai, India. Of the 37 patients included in the study, 56.7% of patients were asymptomatic or had mild disease and 27% presented with severe symptoms. The recovery rate was 63%, all those who presented with a severe disease succumbed to the infection. Thirty per cent of patients presented with an extended dialysis break due to various logistic and social issues. Though the overall clinical presentation and outcomes of this cohort from a limited resource setting mimic the global scenario, unique social and logistic issues are an additional burden to the patient, caregivers and the health-care facilities, which may worsen the outcomes in the future as the pandemic continues to spread.

Single-dose and Steady-state Pharmacokinetics of Vancomycin in Critically Ill Patients Admitted to Medical Intensive Care Unit of India.

RATIONALE: Vancomycin remains the standard of care for gram-positive bacterial infections, though there are significant developments in newer antibacterial agents. Efficacy can be improved by linking pharmacokinetic with pharmacodynamic principles, thus leading to optimum antibiotic exposure. There is scarcity of pharmacokinetic data in Indian intensive care unit (ICU) population. MATERIALS AND METHODS: Fifteen subjects with suspected or proven gram-positive bacterial infection of either gender between 18 years and 65 years of age were enrolled. Vancomycin at the dose of 1 g every 12 hours was administered over 1-hour period and pharmacokinetic assessments performed on blood samples collected on days 1 and 3. Vancomycin concentrations were measured on validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). RESULTS: The mean C max, elimination half-life, AUC0-12hours, volume of distribution, and clearance of single dose were 36.46 µg/mL (±14.87), 3.98 hours (±1.31), 113.51 µg/mL (±49.51), 52.01 L (±31.31), and 8.90 mL/minute (±3.29), respectively, and at steady state were 40.87 µg/mL (±19.29), 6.27 hours (±3.39), 147.94 µg/mL (±72.89), 56.39 L (±42.13), and 6.98 mL/minute (±4.48), respectively. The elimination half-life increased almost two-fold at steady state. The steady state mean AUC0-24 was 295.89 µg/mL (±153.82). Out of 45 trough levels, 32 (71.11%) concentrations were below recommended range. CONCLUSION: Recommended AUC0-24hours and trough concentrations were not achieved in majority of patients with current dosing, suggesting reevaluation of current vancomycin dosing. Individualized treatment based on close monitoring of vancomycin serum concentrations in critically ill patients is imperative. HOW TO CITE THIS ARTICLE: Mali NB, Deshpande SP, Wandalkar PP, Gupta VA, Karnik ND, Gogtay NJ, et al. Single-dose and Steady-state Pharmacokinetics of Vancomycin in Critically Ill Patients Admitted to Medical Intensive Care Unit of India. IJCCM 2019;23(11):513-517.

A Multicentric, Prospective, Observational Antibacterial Utilization Study in Indian Tertiary Referral Centers.

RATIONALE: Antibacterials are largely prescribed to the intensive care unit (ICU) patients due to high prevalence of infections. However, appropriate use of antibacterials is imperative; since the misuse of antibacterials increases antibacterial resistance and ultimately, it has negative impact on health care and economic system. Hence, continuous antibacterials prescription assessments are very important to judge and improve prescription patterns. The present work was carried out at public and private hospitals to assess the differences in antibacterial prescribing pattern. METHODS: The present study was conducted at three public and two private hospitals over the period of 14 months. Demographic and drug use details were captured daily from patients admitted to medical ICUs to assess the World Health Organization indicators. RESULTS: A total of 700 patients were enrolled across the five centers (140 per center), among them 424 were male and 276 were female. Average number of drugs and antibacterials prescribed at public hospitals are significantly higher than the private hospital. However, percentage of antibacterial agents prescribed at public hospitals was significantly lower than the private hospitals (P = 0.0381). Private hospitals had significantly lower percentage of antibacterial agents prescribed by generic name (P < 0.0001). Differences in change of antibacterial agents required were not statistically significantly different (P = 0.1888); however, significant difference was observed in percentage of patients who received antibacterial treatment as per sensitivity pattern (P = 0.0385) between public and private hospitals. Significantly higher mortality was observed in public hospitals compared to private hospitals (<0.0001). CONCLUSIONS: More generic prescriptions and more number of prescriptions as per the sensitivity pattern are required at each public and private hospital.

SOFA Score and Critically Ill Elderly Patients.

OBJECTIVE: To study correlation between SOFA Score and Outcome in Elderly Patients admitted In Intensive Care Unit. METHODS: A single centre prospective observational study in Medical Intensive Care Unit (MICU) of large teaching Institute. A total of 84 elderly patients were studied and the outcome was correlated with SOFA Score at admission and 48 hours after admission. RESULTS: Elderly patients constituted 10.94% (84 out of 764) of total MICU admissions. Critically ill elderly patients had a very high mortality of 73.8% (62 out of 84), as compared to their younger counterparts with mortality rates of 43.53% (296 out of 680) with a highly significant P value of <0.0001. The mean SOFA scores are statistically significantly higher at both time points in the expired group (7.84±3.74 and 8.64±3.72 respectively on admission and at 48 hours). CONCLUSIONS: There is positive correlation between mortality and SOFA score at admission and at 48 hours. SOFA score thus can be effectively used as predictive scoring system for critically ill elderly patients.

Life-threatening Medical Complications Due to Ovarian Hyperstimulation Syndrome: A Hidden Etiology.

Ovarian hyperstimulation syndrome is usually an iatrogenic complication in women taking ovulation induction medications during assisted reproduction. We hereby report the case of a 25 years old female who presented with hypertension, polyserositis with tense ascites and large cystic ovaries. She developed sigmoid and transverse sinus thrombosis. She had undergone a clandestine ovulation induction therapy as a commercial ovum donor. She fitted in severe category of ovarian hyperstimulation syndrome.