Audiological Evaluation of Leprosy Patients in an Endemic Area of Central India: A Case-Control Pilot Study.

There are discrepancies in the literature about the specific influence of leprosy on auditory functions. In routine clinical practice regular hearing screening of leprosy patients is not done. Due to conflicting reports of auditory system involvement in the literature, we conducted this case control study to evaluate the need of regular hearing screening in leprosy patients. A complete otological examination of thirty leprosy patients was conducted. Thirty age and sex matched healthy individual attending ear, nose and throat outpatient department were enrolled as control. Ten cases (33.3%) out of the thirty leprosy patients were found to have high frequency (4 and 8 kHZ) sensorineural hearing loss. The results of this study suggest that leprosy patients require routine monitoring for auditory functions for early identifications of sensorineural hearing loss. As our study is a case-control study with small sample size, in future large prospective studies are required to evaluate the correlation of hearing loss with leprosy and to see the progression hearing loss. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04381-1.

Covid-Associated Mucormycosis in a Case of Wegener's Granulomatosis: A Management Challenge.

A Gentleman in his 40s presented to us with left-sided hemifacial pain and nasal discharge for the last three days. He has been on immunosuppressive therapy for Wegener's Granulomatosis for over five years. Crusting was seen in the Left middle meatus upon clinical examination. Based on the post-covid status, steroid therapy, KOH mount, and radiologic imaging, a provisional diagnosis of Sinonasal mucormycosis was considered. He was posted for emergency debridement followed by Liposomal Amphotericin B and steroid therapy. Surgical histopathological specimens were suggestive of Mucormycosis. Limited sinonasal disease with no intracranial, orbital, or palatal involvement was seen in a background of Wegener's Granulomatosis, Covid, and immunosuppressive therapy. Steroids are condemned as a predisposing factor to mucormycosis. Still, the combination of Liposomal Amphotericin B and steroids was used, opening new avenues for managing mucormycosis in patients with vasculitis. The patient is well nine months post-surgery with no signs of disease relapse.

Skull Base Involvement in Covid Associated Rhino-Orbital-Cerebral Mucormycosis: A Comprehensive Analysis.

The base of skull forms the first line of barrier to be breached in the transition of rhino-orbito-palatal forms of mucormycosis to intracranial forms with various neurological deficit. The pattern of base of skull erosion has prognostic implications in overall recovery and survival of the patient. The aim of the study was to assess the pattern of skull base involvement in cases of rhino-orbital-cerebral mucormycosis (ROCM) in terms of clinical presentations, radiological findings, intraoperative illustrations and post operative recovery. This is a retrospective single centre study of Covid associated Mucormycosis (CAM) patients with skull base involvement at a tertiary referral centre of central India from May 2021 to October 2021. Amongst a total of 248 patients of CAM, 54 patients with skull base involvement were included in our study. The cases were stratified into basifrontal-BF (15%), basisphenoid-BS (20%), orbital apex-OA (15%), basiocciput-BO (26%), frontal bone osteomyelitis-FBO (22%) and sphenoid bone osteomyelitis-SBO (2%), based on their pattern of involvement of skull base and intracranial spread. Early ethmoid and cribriform plate involvement progressed to frontal lobe abscess while early maxillary disease progressed to developed temporal lobe abscess. The orbital apex lesions had early onset cavernous sinus thrombosis. Analysis of clinical manifestations and postoperative follow up revealed an emerging pattern where Posterosuperior lesions of paranasal sinuses (Ethmoid, roof of maxilla and orbit) progressing to BF, BS, OA, FBO and SBO had poorer treatment outcome than Anteroinferior (Floor of maxillary sinus, palate) based lesions which involved BO of skull base. The inferiorly located diseases had better prognosis, less duration of hospital stay, lesser mortality and decreased need for second surgery. There exists a temporal relation of the initial site of fungal load in sinonasal region to their subsequent intracranial spread. Classification into subtypes helped in disease stratification which helped in prognostication and surgical planning. Early intervention by multidisciplinary team improved survival outcome.

Rhinocerebral mucormycosis (RCM): To study the clinical spectrum and outcome of 61 cases of RCM managed at a tertiary care center in India.

Background: Mucormycosis is a life-threatening infection of the paranasal sinuses and nasal cavities that can easily spread to the orbit and the brain. It is caused by fungi of the family Mucoraceae. We present a case series of 61 patients diagnosed and treated for rhinocerebral mucormycosis (RCM) at a single tertiary health care center. Methods: After obtaining ethical clearance, all patient files with a final diagnosis of RCM were thoroughly analyzed in departmental records and a master chart was prepared. The study evaluated the etiology, clinical spectrum, diagnosis, management, complications, and outcome at 3 months of RCM cases. Results: About 93.4% of the RCM cases were diabetic and an equal number had a past history of COVID infection. About 85.2% had received steroids for the treatment of coronavirus disease 2019 infection. The most common presentation of RCM was temporal lobe abscess (25.7%) followed by frontal lobe abscess (16.6%). At 3 months post-diagnosis, mortality in our study was 42.6%. About 26.2 % of the RCM cases had no disease, 23% had a static disease, and 8.2% had progressive disease at the end of 3 months. Conclusion: We report the largest single-center case series of RCM, comprising 61 patients. This case series underscores the importance of the early diagnosis and prompt treatment for a better prognosis for this dreadful disease. The three pillars of treatment for RCM cases include reversal of the immunosuppressive state, administration of antifungal drugs, and extensive surgical debridement. In spite of all this, mortality remains high.

Epidemic in pandemic: Fungal sinusitis in COVID-19.

Objective: To describe the clinical pattern of invasive fungal sinusitis in COVID-19 and post-COVID-19 cases. Methods: All patients affected by COVID-19 or having a history of COVID-19 infection with an invasive fungal lesion (mucormycosis/aspergillosis) of the paranasal sinuses, orbit, palate, brain, lung, skin/cheek, and dental has been evaluated for possible description in tertiary care hospital in May 2021. Results: Twenty-four patients presented with clinical signs and symptoms of fungal infection with a history of COVID-19. Paranasal sinuses were involved in all patients. Palatal involvement was seen in seven cases. Intraorbital extension was seen in 13 cases. Intracerebral involvement was seen in three cases. Comorbid type 2 diabetes was seen in 20 patients. The use of steroids was noticed in 16 cases. Our observation revealed that uncontrolled diabetes, overuse of steroids, increased ferritin levels, and low hemoglobin percentage are the main factors aggravating mucormycosis.

Pharyngocutaneous Fistula Following Primary Total Laryngectomy: a Meta-analysis.

Pharyngocutaneous fistula (PCF) is the most common complication which significantly increases morbidity. High-level evidence is lacking that determines the PCF rates in the primary laryngectomy. The main objective of this study was to systematically identify the factors leading to the PCF formation in primary laryngectomy. Human studies reporting at least one risk factor for developing PCF in patients undergoing primary total laryngectomy for laryngeal cancer were included. PubMed, EMBASE, and Cochrane databases were searched for the data extraction. Risk of bias assessment tool for non-randomized trial tool was used. Cochrane's Q test and Higgin's I 2-heterogeneity was applied. The Mantel-Haenszel and DerSimonian Laird method was employed. Odds ratio was calculated for each risk factor, a P-value < 0.05 was considered as statistically significant. PROSPERO registration CRD42021248382. The meta-analysis comprised a total of 2446 patients in 14 included non-randomized studies. The among the analyzed risk factors-comorbidities (OR 2.781, R: 1.892-4.088, P < 0.001), site of tumor (OR 4.485, R: 3.003-6.699, P < 0.001), low pre-operative hemoglobin (OR 3.590, R: 2.130-6.050, P < 0.001), low pre-operative albumin (OR 2.833, R: 1.596-5.031, P < 0.001), utilization of surgical staplers (OR 0.172, R: 0.064-0.460, P < 0.001) (protective effect), positive mucosal margin (OR 4.92 R: 1.90-12.75, P = 0.001). The risk factors for PCF in patients undergoing primary TL included comorbidities, hypopharyngeal involvement, pre-operative hemoglobin and albumin, stapler usage, and positive mucosal margin. Level of Evidence - III. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01581-z.

Facial Nerve Palsy in COVID-19-Associated Mucormycosis Patients: A Case Series.

Sinonasal mucormycosis is a deadly fungal illness that primarily affects diabetics who are uncontrolled. Numerous cranial nerves can be involved; however, facial nerve palsy has only been observed in a few cases. The main objective of this research is to highlight facial nerve involvement as a clinical sign of sinonasal mucormycosis. Nasal stuffiness, headaches, eye pain, orbital edema, ophthalmoplegia, and vision loss are common symptoms in these mucormycosis patients. The study was done in the Department of Otolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences (AIIMS), Raipur, India. Nevertheless, 17 patients with facial nerve palsy (lower motor nerve palsy) and sinonasal mucormycosis arrived at our department. All patients were diabetic, and a majority of patients got Schirmer's test positive with severe stage. In the case of mucormycosis, facial nerve palsy is an unusual but noteworthy symptom. This could be misinterpreted as a cerebrovascular accident (CVA), causing the therapy to be delayed. This is critical as early identification, surgical debridement, and adequate therapy of the underlying metabolic imbalance, as well as amphotericin B, are critical for a successful treatment outcome in mucormycosis.

Update on the Use of Biologic Therapy in Ulcerative Colitis.

OPINION STATEMENT: Ulcerative colitis (UC) is a major form of inflammatory bowel disease and is characterized by chronic inflammation of the colon and rectum and by alternating periods of flares and remissions. Symptoms may include rectal bleeding, abdominal pain, and diarrhea. The pathogenesis of UC is complex and involves a combination of immune dysregulation, genetics, environmental factors, and microbiota. The goal of medical treatment is to induce and maintain remission. Traditionally, the treatment options for UC included 5-aminosalicylates, corticosteroids, and immunomodulators. However, over the past decade, with the approval of various biologic agents for treatment of UC, the management of UC has been revolutionized. Currently, the FDA-approved biologics for treatment of UC include infliximab, adalimumab, golimumab, and vedolizumab. There are a number of other agents which are under investigation and may become available soon as treatment options for UC. The purpose of this article is to provide a summary of various biologics in the treatment of UC.

Diagnosis of cystic lymphangioma of the colon by endoscopic ultrasound: Biopsy is not needed!

Cystic lymphangioma of the colon (CLC) is a rare benign lesion that is usually asymptomatic and found incidentally during colonoscopy. Limitations in the conventional noninvasive diagnostic techniques have led to surgical resection of these lesions for diagnostic confirmation. Classic endoscopic ultrasound (EUS) findings of colonic cystic lymphangioma are submucosal anechoic cystic spaces with septations, intact muscularis propria, and no solid component. Patients who are asymptomatic with lesions having classic appearance as cystic lymphangioma with EUS can be observed without any intervention. We herein report a case of cystic lymphangioma of distal transverse colon in an asymptomatic patient diagnosed noninvasively using 20-MHz miniprobe EUS and managed conservatively without any surgical intervention.

A rare cause of exercise induced ventricular tachycardia.

Coronary fistulas are anomalous shunts from a coronary artery to a cardiac chamber or great vessel, bypassing the myocardial circulation. A 42-year-old Asian man with no significant history of cardiac disease presented with exertional chest discomfort in the form of chest tightness over the precordial area. The patient had no cardiac risk factors, but given the duration and persistence of symptoms, we did a stress echocardiogram. The exercise led to a 'coronary artery steal phenomenon' caused by the coronary fistula, which diverted the blood from the left anterior descending artery to the pulmonary artery thereby producing the ischemic symptoms and ventricular tachycardia. Transcatheter coil embolization was unsuccessful, but the fistula was eventually closed surgically. A repeat stress echocardiogram before discharge was completely normal. We emphasize the need to individualize treatment, taking into consideration all factors in a particular patient.

Fluid resuscitation in acute pancreatitis.

Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors' recommendations, for predicted severe or severe pancreatitis based on the available evidence.

Pregnancy with portal hypertension.

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of non-cirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes.

Hiatal hernia squeezing the heart to flutter.

An 80-year-old woman presented to the emergency department with failure to thrive and weakness for 14 days. Medical history was significant for polio. On admission her electrocardiogram showed atrial flutter, and cardiac enzymes were elevated. Echocardiogram revealed a high pulmonary artery pressure, but no other wall motion abnormalities or valvulopathies. Chest x-ray showed a large lucency likely representing a diaphragmatic hernia. Computed tomographic scan confirmed the hernia. Our patient remained in atrial flutter despite rate control, and thereafter surgery was consulted to evaluate the patient. She underwent hernia repair. After surgery, the patient was taken off rate control and monitored for 72 hours; she did not have any episode of atrial flutter and was discharged with follow up in a week showing no arrhythmia. Her flutter was caused directly by the mechanical effect of the large hiatal hernia pressing against her heart, as the flutter resolved after the operation.

A new facial expression to botox!

Botulinum toxin (Botox) injection into the lower esophageal sphincter (LES) has been used for the treatment of achlasia cardia since the 1990s. Currently it is indicated for patients who are not candidates for definitive therapy like Heller's myotomy or pneumatic dilation and in those who have recurrence of symptoms after definitive treatments. We present a case of severe anaphylaxix due to Botox. The purpose of this case is to highlight one of the under-reported adverse effects of Botox. Anaphylactic reactions to Botox are very rare with only one other case being reported and have not been emphasized enough to be widely known in clinical practice.

Standard anticoagulation for mesenteric vein thrombosis, revealing a 'zebra' diagnosis: hereditary haemorrhagic telangiectasia--the dripping truth!

A 60-year-old man was treated in the hospital for mesenteric vein thrombosis and discharged home on anticoagulation. On warfarin the patient started to bleed profusely from the nose and tongue. He was evaluated by ENT (ears, nose and throat); a nasal endoscopy revealed several vascular ectasias. Subsequent detailed history and general physical examination established the diagnosis of hereditary haemorrhagic telangiectasia also known as Osler-Weber-Rendu syndrome. On further evaluation, pulmonary arteriovenous malformations were diagnosed on imaging and treated by intervention radiology. In hindsight, the diagnosis could have been made in the general practitioner's office with just a routine thorough history and a physical examination at a new patient visit. We report this case to stress upon the importance of vigilant clinical, medical and family history and a thorough examination to establish an early diagnosis of this not-so-rare entity.

Prevalence of coeliac disease in healthy blood donors: a study from north India.

BACKGROUND: Blood donor screening can help predict prevalence of coeliac disease in population. METHODS: Between December 2010 and June 2011, healthy blood donors were screened using anti-tissue glutaminase antibodies. Those positive underwent duodenoscopy. Their age, gender, body mass index and haemoglobin and histological changes were recorded. RESULTS: Of the 1610 blood donors screened, 1581 (98.2%) were males. The mean age of donors was 31.51 ± 9.66 years and the mean body mass index was 22.12 ± 4.24 kg/m(2). Nine (0.56%) men were seropositive. Endoscopic features included reduced fold height (9), scalloping (8), grooving (7) and mosaic mucosal pattern (3). Eight had Marsh IIIa changes whilst one had IIIb change. The prevalence of coeliac disease was 1:179 (0.56%, 95% confidence interval 1/366-1/91, 0.27-1.1%). None of the 9 patients had any symptoms. Their mean haemoglobin and body-mass index was similar to rest of the cohort. CONCLUSION: The prevalence of coeliac disease amongst apparently healthy blood donors was 1:179 (0.56%).

Long-acting subcutaneously administered insulin for glycemic control immediately after cardiac surgery.

OBJECTIVE: To test the hypothesis that subcutaneous administration of basal insulin begun immediately after cardiac surgery can decrease the need for insulin infusion in patients without diabetes and save nursing time. METHODS: After cardiac surgery, 36 adult patients without diabetes were randomly assigned to receive either standard treatment (control group) or insulin glargine once daily in addition to standard treatment (basal insulin group). Standard treatment included blood glucose measurements every 1 to 4 hours and intermittent insulin infusion to maintain blood glucose levels between 100 and 150 mg/dL. The study period lasted up to 72 hours. RESULTS: There were no differences in demographics or baseline laboratory characteristics of the 2 study groups. Mean daily blood glucose levels were lower in the basal insulin group in comparison with the control group, but the difference was not statistically significant (129.3 ± 9.4 mg/dL versus 132.6 ± 7.3 mg/dL; P = .25). The mean duration of insulin infusion was significantly shorter in the basal insulin group than in the control group (16.3 ± 10.7 hours versus 26.6 ± 17.3 hours; P = .04). Nurses tested blood glucose a mean of 8.3 ± 3.5 times per patient per day in the basal insulin group and 12.0 ± 4.7 times per patient per day in the control group (P = .01). There was no occurrence of hypoglycemia (blood glucose level <60 mg/dL) in either group. CONCLUSION: Once-daily insulin glargine is safe and may decrease the duration of insulin infusion and reduce nursing time in patients without diabetes who have hyperglycemia after cardiac surgery.