Chronic arsenic poisoning: A sinister cause of peripheral neuropathy in a young couple.

ABSTRACT: Arsenic compounds are colorless and odorless and toxicity can occur either acutely following ingestion of arsenicals with gastrointestinal disturbances or due to chronic exposure usually presenting with dermatologic lesions and peripheral neuropathy. We report a young couple who presented with signs and symptoms of painful sensorimotor peripheral neuropathy in a typical "stocking and glove" pattern. They had raised urinary arsenic levels with normal blood levels and thus, a diagnosis of chronic arsenic poisoning due to contaminated water intake was made after detecting elevated arsenic levels in their home water supply. Both patients underwent chelation therapy with dimercaprol for 14 days and reported subjective and objective improvement in symptoms with the reduction in urinary arsenic levels at the end of therapy.

Assessment of CT perfusion indices of the clinicoradiological response to anti-tubercular therapy in patients with intestinal tuberculosis.

AIM: To explore the possibility of using a novel technique, CT perfusion imaging, to monitor the response to anti-tubercular therapy (ATT) in patients with intestinal tuberculosis. MATERIALS AND METHODS: A prospective observational study was performed in adults with treatment naive-intestinal tuberculosis. Clinical, endoscopic, and conventional radiological findings of patients were compared at baseline and post-ATT. CT perfusion imaging was performed with recording of six perfusion parameters (blood flow, blood volume, mean transit time, time to peak, maximum peak intensity, and permeability/blood flow extraction). RESULTS: Twenty-two patients (13 women, 59%) with a median age of 25 years were recruited. The terminal ileum and ileocaecal junction were the most frequent sites of involvement (59%), with multiple segments of the intestine being involved in 16 patients (73%). Median duration of ATT was 6 months (range 6-10 months). Complete clinical response was observed in 22/22 (100%) patients, endoscopic response in 12/12 (100%) patients, and radiological response in 10/13 (76%) patients. There was a significant decrease in mean blood flow, blood volume, maximum peak intensity, and an increase in mean transit time and time to peak on follow-up CT perfusion imaging performed after 6 months of ATT. CONCLUSION: Significant alterations in CT perfusion parameters were demonstrated following treatment, consistent with a decline in inflammation and vascularity. CT perfusion imaging of the bowel is a novel means to assess the radiological response to ATT in intestinal tuberculosis, although at the cost of a higher dose of radiation exposure.

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients.

BACKGROUND: Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India. AIM: Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED). DESIGN: This was a retrospective, single-centre, observational study. METHODS: We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected. RESULTS: Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned. CONCLUSION: COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Myocarditis in admitted patients with dengue fever.

PURPOSE: Cardiac involvement in dengue fever is underdiagnosed due to low index of clinical suspicion and its contribution to hemodynamic instability in severe dengue is not well known. METHODS: A prospective observational study was conducted among admitted patients ≥ 14 years of age having confirmed dengue fever. Patients on medications affecting heart rhythm/rate, pre-existing heart disease and electrolyte abnormalities were excluded. A baseline electrocardiography (ECG), Trop-I and NT-proBNP were done for all patients. The biomarkers were measured using enzyme-linked fluorescent assay and recommended cut-off were used. Patients with elevated biomarkers underwent 2-dimensional echocardiography. Diagnosis of myocarditis was as per European Society of Cardiology (ESC) 2013 criteria. RESULTS: A total of 182 patients were recruited with mean age of 30 ± 12.6 years and 31% were females. Dengue with warning signs was present in 85 (47%) and severe dengue in 60 (33%) patients. ECG abnormalities were observed in 44 (24%) patients, biomarkers were elevated in 27 (15%) patients and 11 (6%) patients had echocardiographic abnormalities. According to ESC 2013 criteria, dengue fever with myocarditis was diagnosed in 13 [7.1% (95% CI 3.4-10.9)] patients. The patients with myocarditis were more likely to have shortness of breath, bleeding manifestations and higher respiratory rate at baseline. Clinical features of fluid overload were more common (69% vs. 1.7%, p < 0.01) and the duration of hospital stay longer in myocarditis group (7 ± 4.3 vs. 4.8 ± 1.9 days, p < 0.01). CONCLUSION: Myocarditis among admitted dengue patients is not uncommon and may lead to increased morbidity.

Scrub typhus in patients with acute febrile illness: a 5-year study from India.

BACKGROUND: Scrub typhus was once thought to be a disease of rural origin and was confined to specific pockets in South Asia. Early diagnosis and treatment is extremely important as it is associated with high mortality if left untreated. AIM: To delineate the clinical and molecular epidemiology of scrub typhus in patients presenting with acute febrile illness from various parts of India. METHODS: During the study period of 5 years (October 2013 to October 2018), a total of 1742 patients with acute febrile illness <15 days were enrolled after taking informed consent. Patients were diagnosed using IgM Enzyme-linked immunosorbent assay (ELISA) based on the pre-determined region specific cut offs. Patients with positive IgM ELISA were also subjected to IgM Immunofluorescence assay and nested polymerase chain reaction (PCR) assay. The demographic and relevant clinical details of the patients were documented and analyzed. RESULTS: A total of 210 (12.1%) patients were diagnosed with scrub typhus. Of these, nested PCR was positive in only 85 patients. Sequencing and phylogenetic analysis showed that the predominant circulating genotypes were Gilliam and Karp. On multivariate analysis, acute respiratory distress syndrome, myocarditis, encephalitis/encephalopathy, jaundice and splenomegaly were significantly more common in those patients who were diagnosed with scrub typhus. A total of 14 patients diagnosed with scrub typhus succumbed to the illness. CONCLUSION: Patients with fever, headache, pulmonary manifestations, CNS manifestations, myocarditis, transaminitis or thrombocytopenia presenting in the monsoon and post-monsoon season should be evaluated for scrub typhus irrespective of the geographical location in India.

Emperor Ashoka: Did he suffer from von Recklinghausen's diseases?

Emperor Ashoka is widely regarded as one of the greatest rulers of India. This paper mainly deals with his medical condition as recorded in the Buddhist texts of Sri Lanka as well as in the Buddhist texts of North India and Nepal. These sources mention his skin disorder which is described as very rough and unpleasant to touch. He is also known to have episodes of loss of consciousness at various times in his life. One of the earliest representations of Ashoka, about 100 years after his death at one of the gates of Sanchi Stupa, shows Ashoka fainting when visiting the Bodhi tree and being held by his queens. In this sculpture, Emperor Ashoka is shown as a man of short height, large head and a paunchy abdomen. In this paper, it is speculated that Emperor Ashoka was probably suffering from von Recklinghausen disease (Neurofibromatosis Type 1), which could explain his skin condition, episodes of loss of consciousness (probably epilepsy) and other bodily deformities.

Progressive multifocal leucoencephalopathy in HIV/AIDS: observational study from a tertiary care centre in northern India.

BACKGROUND & OBJECTIVES: Progressive multifocal leucoencephalopathy (PML) is seen mostly in advanced human immunodeficiency virus (HIV) infection. Little is known about the epidemiology and disease course of these patients from India. This study was aimed to determine the frequency of PML in patients with HIV/AIDS, and the clinical features and survival of these patients. METHODS: The charts of HIV/AIDS patients with PML seen over a period of five years (2006-2011) at the Antiretroviral treatment (ART) centre at a tertiary care centre in New Delhi, India, were retrospectively reviewed. RESULTS: Of 1465 patients with HIV/AIDS, 18 (1.2%) were diagnosed with PML; four were laboratory confirmed and 14 had consistent clinical and radiological features. PML was the initial presentation of HIV infection in 10 (56%) patients, and 16 (89%) patients had CD4 count less than 200/µl. Insidious onset focal limb weakness (78%) and visual disturbance (28%) were common symptoms. Magnetic resonance imaging (MRI) of the brain revealed characteristic white matter lesions in all the patients. The estimated median survival was 7.6 months (95% CI, 0-20 months). INTERPRETATION & CONCLUSIONS: Our results show that the patients present late to access treatment with advanced immunosuppression at presentation. PML is associated with high morbidity and mortality despite institution of highly active antiretroviral therapy (HAART). There is a need to address the lacuna in diagnostic and management services for these patients in India.

Efficacy of two corticosteroid regimens in acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Studies comparing corticosteroids in the management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are lacking. OBJECTIVE: To compare intravenous (IV) methylprednisolone (MP) followed by oral MP with IV hydrocortisone (HC) followed by oral prednisolone in patients with AECOPD. METHODS: Ninety-seven patients with AECOPD were randomly allocated to Group A (n = 50) or Group B (n = 47). Group A patients were administered HC 200 mg 6 hourly until discharge, followed by prednisolone 0.75 mg/kg/day for 2 weeks; Group B patients were administered IV MP (125 mg bolus, followed by 40 mg 6 hourly) and then oral MP 0.6 mg/kg/day for 2 weeks. Clinical variables, peak expiratory flow (PEF) and forced expiratory volume in 1 second (FEV(1)) were assessed until discharge and again 2 weeks after discharge. RESULTS: Baseline characteristics were comparable. Mortality, need for mechanical ventilation and acute exacerbation within 2 weeks of discharge were not significantly different between the two groups. However, at 2 weeks, Group B showed significant improvement over Group A in FEV(1) and PEF. CONCLUSION: This study suggests that in AECOPD, IV MP followed by oral MP produced greater improvement in FEV(1) and PEF than IV HC followed by oral prednisolone, although there were no differences in need for ventilator support or in recurrence of exacerbation.

Dietary adequacy in Asian Indians with HIV.

Malnutrition is endemic in developing countries, which also bear the brunt of the human immunodeficiency virus (HIV) pandemic. HIV and its complications have a significant impact on nutritional status. Malnutrition and HIV have deleterious interactions. Dietary inadequacy is a major cause of malnutrition and few studies have been done to assess dietary adequacy in HIV-infected individuals and the factors affecting intake. Dietary intake of 71 consecutive patients was determined using 24-hour dietary recall, with the help of a questionnaire and a structured interview, and then compared with the recommended dietary allowances (RDA). The dietary intake of energy, total fat, fibre, vitamin C and iron were significantly less than the recommended RDA. There was no difference in protein intake. Only 5.7% of males and 16.7% of females reached the recommended energy allowance. The recommended protein allowance was reached by 43.4% males and 44.4% females and 41.5% males and 38.9% females consumed more than the upper limit of the recommended fat intake. Intake of major nutrients was also significantly less when compared to the national average intake. On bivariate analysis, the factors affecting these inadequacies were found to be annual per-capita income, dependency on another for livelihood, CD4 counts more than 200/cubic millimeter and absence of antiretroviral therapy. On multivariate analysis, only dependency on another was found to significantly influence energy intake. Dietary intake of many food constituents is significantly less in HIV patients than that recommended. Dietary counselling and efforts to improve food security are important in management of these patients.

Screening for HIV infection by health professionals in India.

BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Distribution of CCR2 polymorphism in HIV-1-infected and healthy subjects in North India.

Substitution of V64I in CCR2 relates to delayed progression to AIDS and protects against HIV-1 infection. We examined the distribution of V64I in HIV-infected and healthy North Indian subjects. No significant difference in the allele or genotype distribution of CCR2 V64I polymorphism was observed, indicating that there is no association between CCR2 V64I polymorphism and susceptibility to HIV infection in North Indian population.

Characterization of HIV-1 Gag-specific T cell responses in chronically infected Indian population.

India is at the epicentre of the global HIV/AIDS epidemic in South-east Asia, predominated by subtype C infections. It is important to characterize HIV-1-specific T cell responses in this particular population with the aim of identifying protective correlates of immunity to control HIV-1 infection. In this study, we performed a comprehensive analysis of the breadth and magnitude of T cell responses directed at HIV-1 subtype C Gag, one of the most conserved HIV-1 proteins. The study population consisted of antiretroviral naive, chronic HIV-1 subtype C-infected individuals at various stages of infection. We used recent advanced techniques such as enzyme-linked immunospot (ELISPOT) assay and intracellular cytokine staining to quantify the total CD4(+) and CD8(+) T cell response to HIV-1 gag at single peptide level, regardless of HLA haplotype of the infected individual. The p24-Gag was identified as the most frequently recognized subunit protein with the greatest magnitude of CD4(+) and CD8(+) T cell responses. Stronger and broader CD8 T cell responses were recognized, contrasting with the weaker and narrower CD4 T cell responses with regard to Gag protein subunits. The magnitude of the HIV-specific interferon (IFN)-gamma responses was observed to be higher than the corresponding interleukin (IL)-2 response, indicating the persistence of antigenic load in chronically infected Indian population due to the probable dysfunction of HIV-specific, IFN-gamma-secreting CD8 T cells in absence of IL-2 help.

CDC staging based on absolute CD4 count and CD4 percentage in an HIV-1-infected Indian population: treatment implications.

CD4+ T-cell levels are an important criterion for categorizing HIV-related clinical conditions according to the CDC classification system and are therefore important in the management of HIV by initiating antiretroviral therapy and prophylaxis for opportunistic infections due to HIV among HIV-infected individuals. However, it has been observed that the CD4 counts are affected by the geographical location, race, ethnic origin, age, gender and changes in total and differential leucocyte counts. In the light of this knowledge, we classified 600 HIV seropositive antiretroviral treatment (ART)-naïve Indian individuals belonging to different CDC groups A, B and C on the basis of CDC criteria of both CD4% and CD4 counts and receiver operating characteristic (ROC) curves were generated. Importantly, CDC staging on the basis of CD4% indicated significant clinical implications, requiring an early implementation of effective antiretroviral treatment regimen in HIV-infected individuals deprived of treatment when classified on the basis of CD4 counts.

Tumor necrosis factor-alpha levels in patients with HIV with wasting in South Asia.

Tumor necrosis factor (TNF)-alpha is thought to play an important role in wasting; but TNF-alpha levels have not been consistently found to be high in AIDS wasting. We conducted this study to determine any correlation between TNF-alpha levels and wasting in HIV-positive patients in a developing country. TNF-alpha levels were measured in four groups of patients: Group 1, HIV/AIDS with wasting (n = 25); group 2, HIV/AIDS without wasting (n = 47); group 3, HIV-negative patients with tuberculosis with wasting (n = 25); and group 4, healthy controls (n = 25). Wasting was defined as a body bass index (BMI)