The Clinical Profile and Prognostic Factors Influencing Mortality in Patients With Acute Encephalitis Syndrome.

Introduction Acute encephalitis syndrome (AES) is a significant global public health concern. AES is a disorder characterized by fever and altered mental status, and it is associated with considerable morbidity and mortality. There is a limited amount of existing literature on the clinical profile and prognostic markers that influence mortality in these patients. Our study seeks to comprehend the etiology, clinical characteristics, complications, and prognostic markers that impact mortality among patients with AES.  Methods The study was a prospective observational study conducted over 18 months, involving a sample size of 105 patients. Patients aged 12 years and older, who met the WHO case definition of Acute Encephalitis Syndrome (AES), were consecutively recruited for this study. The patients' details were recorded, including their medical history and physical and clinical examination findings upon admission. The extent of cognitive impairment was evaluated using the Glasgow Coma Scale (GCS). Additionally, the patient's presenting symptoms, any complications experienced during their hospital stay, and the mortality rate were documented. The etiology, MRI results of the brain, laboratory parameters, and the need for assisted ventilation were also recorded. In-hospital characteristics were analyzed using the t-test for continuous variables and the chi-square test for binary variables. The log-rank test was employed to identify the predictors with the most significant independent influence on prognosis. All participants were selected only after obtaining their written informed consent.  Results Most of the patients were in the age group of 21-30. 60% of the patients were male. Advanced age at presentation was associated with an increased risk of mortality (p-value=0.018). All patients presented to the hospital with symptoms of fever and altered sensorium. The most common agent isolated as the etiologic cause was HSV-1, found in 31.4% of the patients. 28.6% of the patients succumbed to death. The leading cause of death was raised intracranial pressure leading to hemorrhage in the brain. There was no significant correlation between the duration of symptoms and the primary outcome of death (p-value=0.498). The requirement for assisted ventilation was shown to increase the risk of death (p-value=0.001). A low GCS score at presentation was associated with a higher mortality rate (p-value=0.048).    Conclusions The factors that predict mortality in AES involve a complex interplay of patient demographics, viral etiology, clinical severity, neuroimaging findings, and the need for assisted ventilation. Integrating these factors into clinical practice would enable healthcare providers to make informed decisions regarding patient management and interventions. As our comprehension of AES continues to develop, forthcoming advancements in diagnostics and therapeutics could refine prognostic assessments further. These developments could open new avenues for enhancing outcomes and diminishing mortality rates in this complex neurological disorder.

Perturbations of immune landscape in COVID-19 associated mucormycosis.

BACKGROUND: A rise in secondary fungal infections during the COVID-19 pandemic necessitates a deeper understanding of the associated immunological perturbations. OBJECTIVES: To evaluate the clinical and immunological characteristics observed in patients with COVID-19 associated mucormycosis (CAM) infection. PATIENTS/ METHODS: Cases of mucormycosis with or post-COVID-19 infection were compared with cases of acute COVID-19 and convalescent COVID-19. Lymphocyte subsets, cytokines and other laboratory markers were compared between the groups. RESULTS: The frequency of proposed risk factors for CAM was diabetes mellitus (77%), recent history of steroid use (69%) and hypoxia during COVID-19 infection (52%). Iron metabolism was dysregulated in CAM patients with low TIBC and total iron. Further, CAM was accompanied with lymphopenia with drastic reduction in B cell counts; however, plasmablasts were not altered. Further, CAM patients had low immunoglobulin levels and antibodies specific to mucor peptide did not increase in CAM suggesting dysfunction in B-cell response. There was increase in activated effector cytotoxic CD8 T cells and NK cells in CAM compared with COVID-19 infection and healthy controls. Among T helper cells, Tregs were reduced and Th-1 frequency was increased in CAM compared with COVID-19 infection. A distinct cytokine signature was evident in CAM with increase in IL-1ß, IFN-γ, IL-6, IL-22, IL-17A, IL-10, IL-2, IL-8, IL-7, IL-21 and GM-CSF. CONCLUSION: This is the first study on immunophenotyping in CAM suggesting the need for long-term monitoring of B-cell function after SARS-CoV-2 in patients with dysregulated glycaemic control and the possible benefit of therapeutic supplementation with intravenous immunoglobulins in CAM.

Efficacy of Pulse Methylprednisolone in Treatment of Acute Respiratory Distress Syndrome due to Malaria: A Randomized Controlled Clinical Trial.

Objective: To study the efficacy of pulse methylprednisolone (MPS) therapy in patients with malaria-associated acute respiratory distress syndrome (ARDS). Materials and methods: The study was a randomized, single-blind, placebo-controlled trial with a total sample size of 44 patients. The total random number table was used on a computer for randomization. The sample size was divided into either the study group that received pulse MPS therapy along with the standard therapy to manage acute lung injury (ALI)/ARDS or the control group that received a placebo in the form of 100 mL of normal saline with the standard therapy to manage ALI/ARDS. The primary outcome was defined as either death of the patient or discharge from the hospital. The sequential organ failure assessment (SOFA) score, the lung injury score (LIS), duration of stay in the medical intensive care unit (MICU), number of days for which mechanical ventilation was required, and the rate of secondary infections between the study and the control groups were also calculated. Statistically significant differences among continuous variables were analyzed by t-test, and differences between categorical variables were assessed by Chi-squared test. Results: A total of 30 patients passed initial screening, out of which 60% were males and 40% were females. About 73.3% of the patients fell between the age groups of 36-45 years. A total of 20 patients (66.7%) were discharged from the hospital, while the remaining 10 patients succumbed to death in the intensive care unit (ICU) (33.3%). The outcome of death or discharge was found to be independent of the use of pulse MPS therapy (p = 0.44). No statistically significant difference was found between the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, SOFA score, and LIS between the two groups. Furthermore, the differences between the mean duration of stay in the MICU, the mean duration for the provision of mechanical ventilation (p = 0.41), and the rate of secondary infections (p = 0.46) remained unaffected with the use of pulse MPS therapy. Conclusion: Pulse MPS therapy has not shown any clear-cut benefit in the management of malaria-associated ARDS, and in fact, the continuous use of this treatment in hospitals may lead to worsened outcomes. A novel, effective therapy for this grave complication needs to be developed to reduce the morbidity and mortality in such patients, which is frequently encountered. The development of a robust surveillance system is required for adequate monitoring and early diagnosis of this complication, along with larger multicentric randomized clinical trials. Disclosures: Approval was granted by the Institutional Ethics Committee (IEC). All participants were only selected after taking their written informed consent. The authors have no conflicts of interest or acknowledgments to report. How to cite this article: Tiwari S, Kursange S, Goyal A, et al. Efficacy of Pulse Methylprednisolone in Treatment of Acute Respiratory Distress Syndrome due to Malaria: A Randomized Controlled Clinical Trial. J Assoc Physicians India 2023;71(11):36-39.

Clinical Study of Use of Remdesivir and Tocilizumab in Severely Ill COVID-19 Patients.

Introduction: Remdesivir and Tocilizumab are two experimental drugs used in severely ill COVID-19 patients. Various clinical trials studying these drugs are giving conflicting results. Our aim is to study these two drugs and share the experience in our setting. Methods: Our Study is a retrospective analysis of Clinico-laboratory details and outcome of three groups of patients who were given either (i) Remdesivir or (ii) Tocilizumab or (iii)both Remdesivir and Tocilizumab . We compared the outcome of these patients with other patients who did not receive either of these drugs, when it was not available or not introduced as experimental drugs earlier in treatment guidelines. Results: Out of a total of 521 patients, in the above three groups who received either or both Remdesivir or Tocilizumab, 334 survived. Out of 214 patients who did not receive any of the two drugs only 74 survived. The outcome was better individually for all the three groups of patients receiving either or both of the drugs as compared to neither of the drugs.(p <0.01) Conclusion: Remdesivir and Tocilizumab were useful drugs in treatment of severely ill covid -19 patients as compared with the patients who did not receive any of the above drugs.

Neurological Emergencies in HIV Patients.

INTRODUCTION: HIV AIDS epidemic currently in India is quite under control, the efforts of NACO and community at large has lead to this. The current prevalence of HIV among adults is around) 0.3%, the widespread prevention and control strategies are the main reason behind the same. HAART coverage has also increased significantly which has played a major role in not only controlling the epidemic but also in the change of clinical scenario and clinical affection in patients of HIV AIDS. The neurological complications arising in HIV patients, either due to opportunistic infections or due to the disease per say have also declined due to early and effective HAART.