Herpes Simplex Virus Encephalitis: An Unexpected Outcome in a Polytrauma Patient.

An 84-year male was brought in the emergency after a road traffic accident leading to polytrauma with deteriorating consciousness. Prolonged unexplained unconsciousness led to cerebrospinal fluid examination. The polymerase chain reaction (PCR) of cerebrospinal fluid (CSF) was found to be positive for HSV-1 DNA. The patient was started on intravenous acyclovir and the consciousness level of the patient improved gradually. In this case, encephalitis was not suspected initially, because of the multiple traumatic injuries that needed management. Moreover, no features suggestive of encephalitis were present at the time of presentation, except for the non-specific symptom of drowsiness at the time of the accident. The patient was also diabetic and had chronic kidney disease as predisposing factors. It was primarily encephalitis which led to impaired consciousness that resulted in the road traffic accident in a very unlikely situation, i.e., hit by an ambulance inside the hospital. The reasons to suspect herpes simplex virus encephalitis (HSE) in this case were unexplained worsening level of consciousness, CSF findings suggestive of viral encephalitis along with highly deranged alanine aminotransferase (ALT) levels. This case highlights the importance of keeping a high index of suspicion for viral encephalitis in patients with risk factors, even in such a scenario of polytrauma. Key Words: Herpes simplex virus, Polytrauma, Viral encephalitis, Polymerase chain reaction.

Invasive fungal disease in critically ill and Immunocompromised patients.

OBJECTIVE: To study the frequency and type of invasive fungal disease in critically ill and immunocompromised patients. Method: The prospective, cross-sectional, descriptive study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from January 2017 to December 2020, and comprised pathological samples from immunocompromised and critically ill patients for fungal culture. Data regarding demographics, comorbidities, results of direct microscopy and fungal culture was recorded. Data was analysed using SPSS 22. RESULTS: Of the 8285 patients' specimens, 4722(57%) belonged to males and 3563(43%) to females. The mean age of the patients was 48.32±5.42 years (range: 14-98 years). Out of total 8285, 3465(41.82%) were related to blood, 2640(32%) endobronchial washing, 837(10%) sputum, 623(7.5%) tissue, 332(4%) body fluids, 288(3.5%) bronchoalveoar lavage and 100(1.2%) cerebrospinal fluid. Aspergillus flavus (20.7%) and candida albicans (14.5%) were the two most commonly isolated fungal species. CONCLUSIONS: A high index of suspicion for invasive fungal disease should be maintained in immunocompromised and critically ill patients.

Evaluation of galactomannan and beta-d-glucan assays for the diagnosis of invasive aspergillosis in clinically suspected cases.

OBJECTIVE: To assess the utility of galactomannan and beta-D-glucan assays in the diagnosis of invasive aspergillosis in clinically suspected cases, and to compare their diagnostic potential to determine whether a combination of the two may result in an early and specific diagnosis. METHODS: The descriptive cross-sectional case-control study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from April 1, 2017, to March 31, 2018, and comprised serum samples from clinically suspected invasive aspergillosis patients and healthy controls. The sera were tested for galactomannan and beta-D-glucan detection. Proven, probable and possible categories of invasive aspergillosis according to European Organisation for Research and Treatment of Cancer / Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria. Galactomannan antigen was detected using a one-stage immunoenzymatic sandwich microplate assay. Beta-D-Glucan antigen was detected using a protease zymogen-based colorimetric assay. Sensitivity and positive / negative likelihood ratio of both the cases and the controls were calculated and compared. RESULTS: Of the 178 subjects, 119(67%) were cases and 59(33%) were controls. Beta-D-glucan assay was more sensitive than galactomannan assay (91.6% versus 80.67%) whereas galactomannan assay was more specific than beta-D-glucan assay (86.44% versus 76.27%) in the diagnosis of invasive aspergillosis. The sensitivities of both assays decreased with decreasing probability of invasive aspergillosis, i.e., maximum sensitivities of both beta-D-glucan and galactomannan assays were for proven cases (100% versus 87.5%), followed by probable cases (89.29% versus 85.71%), and possible cases (91.57% versus 78.31%). CONCLUSIONS: Both beta-D-glucan and galactomannan assays seemed to play an encouraging role in the diagnosis of invasive aspergillosis in high-risk clinically suspected cases, with the former assay being more sensitive and the latter assay being more specific.